Provider Demographics
NPI:1356621130
Name:THOMPSON, JOHNATHAN H (DO)
Entity type:Individual
Prefix:DR
First Name:JOHNATHAN
Middle Name:H
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1324 LAKELAND HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-4543
Mailing Address - Country:US
Mailing Address - Phone:863-687-1100
Mailing Address - Fax:904-450-6401
Practice Address - Street 1:1324 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-4543
Practice Address - Country:US
Practice Address - Phone:863-687-1321
Practice Address - Fax:863-284-1786
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-24
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA78645207XX0801X
PAOT015575207XX0801X
FLUO2822208D00000X
FLOS15270207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic TraumaGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024956000Medicaid