Basic Information
| Provider Information | |||||||||
| NPI: | 1659367951 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THAMPY | ||||||||
| FirstName: | KISHORE | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4310 METRO PKWY | ||||||||
| Address2: | STE 205 | ||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339169416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392232751 | ||||||||
| FaxNumber: | 2395612933 | ||||||||
| Practice Location | |||||||||
| Address1: | 11820 BEACH BLVD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322459249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046429100 | ||||||||
| FaxNumber: | 9046429108 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2005 | ||||||||
| LastUpdateDate: | 12/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | ME105361 | FL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 260025865 | 01 | IL | RAILROAD MEDICARE | OTHER | 1133389 | 05 | IA | MEDICAID | P00134680 | 01 | IA | RAILROAD MEDICARE | OTHER | 0216041 | 01 | IL | BLUE SHIELD | OTHER | 036048133 | 05 | IL | MEDICAID |