Provider Demographics
NPI:1336433507
Name:THOMPSON, MATTHEW MICHAEL (DO)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:MICHAEL
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3330
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84110-3330
Mailing Address - Country:US
Mailing Address - Phone:888-333-1095
Mailing Address - Fax:770-701-6674
Practice Address - Street 1:34800 BOB WILSON DRIVE
Practice Address - Street 2:NAVAL MEDICAL CTR
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-5000
Practice Address - Country:US
Practice Address - Phone:619-545-4359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-06
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE943208D00000X
ORDO201761207L00000X
CA20A17688207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAVAD0000Medicare UPIN