Healthcare Provider Details

I. General information

NPI: 1356621130
Provider Name (Legal Business Name): JOHNATHAN H THOMPSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2011
Last Update Date: 10/19/2022
Certification Date: 10/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1324 LAKELAND HILLS BLVD
LAKELAND FL
33805-4543
US

IV. Provider business mailing address

1324 LAKELAND HILLS BLVD
LAKELAND FL
33805-4543
US

V. Phone/Fax

Practice location:
  • Phone: 863-687-1321
  • Fax: 863-284-1786
Mailing address:
  • Phone: 863-687-1100
  • Fax: 904-450-6401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number78645
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License NumberOT015575
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberUO2822
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License NumberOS15270
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: