MEDICARE: MARK THOMPSON DPM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0103X	Foot & Ankle Surgery Podiatrist	2398	TX
2	390200000X	Student in an Organized Health Care Education/Training Program	SC006749	PA
3	213ES0103X	Foot & Ankle Surgery Podiatrist	2394	TX

General Provider Information

NPI Number	:	1750733119
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK THOMPSON DPM

Provider Business Mailing Address
First Line	:	6312 AZLE AVE
Second Line	:
City	:	LAKE WORTH
State	:	TX
Zip	:	76135-2442
Country	:	US
Telephone Number	:	817-238-8400
Fax Number	:	817-238-8401

Provider Business Practice Location Address
First Line	:	6312 AZLE AVE
Second Line	:
City	:	LAKE WORTH
State	:	TX
Zip	:	76135-2442
Country	:	US
Telephone Number	:	817-238-8400
Fax Number	:	817-238-8401

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/11/2016
Last Update Date	:	02/08/2023

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Directions to “ MARK THOMPSON DPM” Practice Location

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