Healthcare Provider Details

I. General information

NPI: 1568469971
Provider Name (Legal Business Name): WESLEY D THOMPSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 05/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 NW 10TH ST
FAIRFIELD IL
62837-1219
US

IV. Provider business mailing address

213 NW 10TH ST SUITE A
FAIRFIELD IL
62837-1219
US

V. Phone/Fax

Practice location:
  • Phone: 618-842-4617
  • Fax: 618-842-4743
Mailing address:
  • Phone: 618-842-4617
  • Fax: 618-842-4743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036108349
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: