Healthcare Provider Details

I. General information

NPI: 1346828340
Provider Name (Legal Business Name): SAMUEL LIAM THOMPSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2021
Last Update Date: 07/14/2025
Certification Date: 07/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 16TH ST FL 4 BOX 0110
SAN FRANCISCO CA
94158-2604
US

IV. Provider business mailing address

550 16TH ST FL 4 BOX 0110
SAN FRANCISCO CA
94158-2604
US

V. Phone/Fax

Practice location:
  • Phone: 628-588-6362
  • Fax:
Mailing address:
  • Phone: 628-588-6362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD2024-0459
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberA201047
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: