Provider Demographics
NPI:1205007382
Name:THOMPSON, MAVIS S (MD)
Entity type:Individual
Prefix:
First Name:MAVIS
Middle Name:S
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 MADISON AVE
Mailing Address - Street 2:FLOOR 6
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-7802
Mailing Address - Country:US
Mailing Address - Phone:212-545-2439
Mailing Address - Fax:646-312-0481
Practice Address - Street 1:81 W 115TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10026-3138
Practice Address - Country:US
Practice Address - Phone:212-426-0088
Practice Address - Fax:212-423-8367
Is Sole Proprietor?:No
Enumeration Date:2008-03-18
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY076153207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00695941Medicaid
NY331946Medicare Oscar/Certification