Healthcare Provider Details

I. General information

NPI: 1548805393
Provider Name (Legal Business Name): BLAKE THOMPSON MD INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2019
Last Update Date: 11/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 FRIARS RD STE 400
SAN DIEGO CA
92108-5862
US

IV. Provider business mailing address

9040 FRIARS RD STE 400
SAN DIEGO CA
92108-5862
US

V. Phone/Fax

Practice location:
  • Phone: 619-284-6377
  • Fax:
Mailing address:
  • Phone: 619-284-6377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. BLAKE R THOMPSON
Title or Position: PRESIDENT
Credential: MD
Phone: 619-284-6377