Healthcare Provider Details

I. General information

NPI: 1992870471
Provider Name (Legal Business Name): GREGORY JOHN THOMSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 12/19/2020
Certification Date: 12/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 E BROADWAY AVE
JACKSON WY
83001-8640
US

IV. Provider business mailing address

220 W PEARL ST UNIT 4313
JACKSON WY
83001-5473
US

V. Phone/Fax

Practice location:
  • Phone: 833-437-4863
  • Fax: 949-561-4107
Mailing address:
  • Phone: 503-913-5548
  • Fax: 949-561-4107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License NumberMEDS7811
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number12812A
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: