Healthcare Provider Details

I. General information

NPI: 1104898386
Provider Name (Legal Business Name): RYAN STEWART THOMPSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 01/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 BIG TREES RD STE E
MURPHYS CA
95247-9101
US

IV. Provider business mailing address

PO BOX 1049
MURPHYS CA
95247-1049
US

V. Phone/Fax

Practice location:
  • Phone: 209-728-2021
  • Fax: 209-728-8752
Mailing address:
  • Phone: 209-728-2021
  • Fax: 209-728-8752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG058580
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: