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General NPI Number Information
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NPI Number | 1083275762
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Entity Type | Individual
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Provider Name | TYLER BRADSHAW THOMPSON IDC
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Gender | Male
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Dates
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Enumeration Date | 06/24/2019
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Last Update Date | 06/24/2019
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Provider Practice Location Address
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Address Line | 34, FARENHOLT AVE
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City | SAN DIEGO
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State | CA
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Zip | 92134-0001
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Country | US
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Telephone | 619-532-7962
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Fax |
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Provider Business Mailing Address
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Address Line | 10061 RIO SAN DIEGO DR APT 302
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City | SAN DIEGO
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State | CA
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Zip | 92108-5659
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Country | US
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Telephone | 740-424-5556
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171000000X
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Taxonomy Name | Military Health Care Provider
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License Number |
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License Number State |
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