Basic Information
| Provider Information | |||||||||
| NPI: | 1104188390 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOMPSON | ||||||||
| FirstName: | MELANIE | ||||||||
| MiddleName: | ROSE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SOUTHARD | ||||||||
| OtherFirstName: | MELANIE | ||||||||
| OtherMiddleName: | ROSE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6090 REDWOOD BLVD G | ||||||||
| Address2: | |||||||||
| City: | NOVATO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949454569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4157983106 | ||||||||
| FaxNumber: | 4157983180 | ||||||||
| Practice Location | |||||||||
| Address1: | 155 N FRESNO ST | ||||||||
| Address2: | ATTN: FAMILY MEDICINE | ||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937012302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594996450 | ||||||||
| FaxNumber: | 5594996451 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2012 | ||||||||
| LastUpdateDate: | 05/08/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 13078 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.