Healthcare Provider Details

I. General information

NPI: 1306859103
Provider Name (Legal Business Name): JEAN G THOMPSON B.C.O
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4118 MCCULLOUGH AVE SUITE 16
SAN ANTONIO TX
78212-1979
US

IV. Provider business mailing address

4118 MCCULLOUGH AVE SUITE 16
SAN ANTONIO TX
78212-1979
US

V. Phone/Fax

Practice location:
  • Phone: 210-223-3754
  • Fax: 210-223-1949
Mailing address:
  • Phone: 210-223-3754
  • Fax: 210-223-1949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1700X
TaxonomyOcularist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: