Healthcare Provider Details

I. General information

NPI: 1639480759
Provider Name (Legal Business Name): CARLIE KENNEDY THOMPSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARLIE REBECCA KENNEDY M.D.

II. Dates (important events)

Enumeration Date: 06/23/2010
Last Update Date: 12/27/2019
Certification Date: 12/27/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 S BUENA VISTA ST STE 415
BURBANK CA
91505-4541
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 818-333-2555
  • Fax: 818-333-2559
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number127831
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberA127831
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: