Provider Demographics
NPI:1447452560
Name:THOMPSON, CHAD
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3330 NW 56TH ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-4479
Mailing Address - Country:US
Mailing Address - Phone:405-945-4740
Mailing Address - Fax:405-945-4751
Practice Address - Street 1:3330 NW 56TH ST
Practice Address - Street 2:SUITE 206
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4479
Practice Address - Country:US
Practice Address - Phone:405-945-4740
Practice Address - Fax:405-945-4751
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK249662085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200246380AMedicaid
OK344464YNR6 AIMedicare PIN
OK344464YPK2 MPIMedicare PIN
OK200246380AMedicaid