Healthcare Provider Details

I. General information

NPI: 1205831997
Provider Name (Legal Business Name): FREDERICK L THOMPSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 S ADAMS ST
NEVADA MO
64772-3210
US

IV. Provider business mailing address

900 S ADAMS ST
NEVADA MO
64772-3210
US

V. Phone/Fax

Practice location:
  • Phone: 417-667-6015
  • Fax: 417-667-3007
Mailing address:
  • Phone: 417-667-6015
  • Fax: 417-667-3007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR8308
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: