Provider Demographics
NPI:1255375689
Name:THOMPSON, ELISA J (MD)
Entity type:Individual
Prefix:
First Name:ELISA
Middle Name:J
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELISA
Other - Middle Name:T
Other - Last Name:RUKSZNIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:120 MEDICAL BLVD STE 103
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34609-0221
Practice Address - Country:US
Practice Address - Phone:352-340-2115
Practice Address - Fax:352-340-2116
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME16013207Q00000X
FLME125969207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEP00245819OtherRAILROAD MEDICARE
ME255720099Medicaid
MEP00245819OtherRAILROAD MEDICARE
MEMM9834Medicare ID - Type Unspecified