Healthcare Provider Details

I. General information

NPI: 1689650939
Provider Name (Legal Business Name): DAVID IMMANUEL THICKMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 05/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 SOPRIS MESA DR
CARBONDALE CO
81623-3150
US

IV. Provider business mailing address

11995 SINGLETREE LANE, STE 500
EDEN PRAIRIE MN
55344-5349
US

V. Phone/Fax

Practice location:
  • Phone: 952-595-1100
  • Fax: 612-294-4903
Mailing address:
  • Phone: 952-595-1301
  • Fax: 612-294-4903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberDR28103
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: