Healthcare Provider Details

I. General information

NPI: 1609105493
Provider Name (Legal Business Name): CLINTON EDWARD THOMPSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2009
Last Update Date: 12/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60991 BELL SPRINGS ROAD
LAYTONVILLE CA
95454-0603
US

IV. Provider business mailing address

PO BOX 603
LAYTONVILLE CA
95454-0603
US

V. Phone/Fax

Practice location:
  • Phone: 707-272-0782
  • Fax: 650-745-0869
Mailing address:
  • Phone: 707-272-0782
  • Fax: 650-745-0869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA45458
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: