Provider Demographics
NPI:1770808420
Name:KEITH P. THOMPSON MD PC
Entity type:Organization
Organization Name:KEITH P. THOMPSON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:P
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-666-5076
Mailing Address - Street 1:4505 ASHFORD DUNWOODY ROAD
Mailing Address - Street 2:SUITE 15
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30346-1516
Mailing Address - Country:US
Mailing Address - Phone:678-666-5076
Mailing Address - Fax:678-666-5076
Practice Address - Street 1:4505 ASHFORD DUNWOODY ROAD
Practice Address - Street 2:SUITE 15
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30346-1516
Practice Address - Country:US
Practice Address - Phone:678-666-5076
Practice Address - Fax:678-666-5076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-06
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031339261QS0132X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10636649OtherCAQH