Provider Demographics
NPI:1083618722
Name:THOMPSON, TEDDY LEONARD (MD)
Entity Type:Individual
Prefix:MR
First Name:TEDDY
Middle Name:LEONARD
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1342 BARSON PLACE
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650
Mailing Address - Country:US
Mailing Address - Phone:608-317-4644
Mailing Address - Fax:608-783-5426
Practice Address - Street 1:1526 ROSE STREET
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54603
Practice Address - Country:US
Practice Address - Phone:608-317-4644
Practice Address - Fax:608-783-5426
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20493207Q00000X
WIWI20493207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30561200Medicaid
WI0177Medicare ID - Type Unspecified
B85314Medicare UPIN