Healthcare Provider Details

I. General information

NPI: 1336433507
Provider Name (Legal Business Name): MATTHEW MICHAEL THOMPSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2011
Last Update Date: 03/02/2021
Certification Date: 03/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34800 BOB WILSON DRIVE NAVAL MEDICAL CTR
SAN DIEGO CA
92134-5000
US

IV. Provider business mailing address

PO BOX 3330
SALT LAKE CITY UT
84110-3330
US

V. Phone/Fax

Practice location:
  • Phone: 619-545-4359
  • Fax:
Mailing address:
  • Phone: 888-333-1095
  • Fax: 770-701-6674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberDO201761
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number20A17688
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number943
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: