Provider Demographics
NPI:1144224783
Name:THOMPSON, THEODORE (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:
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 1:105 W STONE DR
Mailing Address - Street 2:SUITE 6A
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3365
Mailing Address - Country:US
Mailing Address - Phone:423-408-7220
Mailing Address - Fax:423-408-7405
Practice Address - Street 1:1220 VOLUNTEER PKWY
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-4628
Practice Address - Country:US
Practice Address - Phone:423-274-6610
Practice Address - Fax:423-274-6619
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD38948207R00000X
VA0101055839207R00000X
TN38948207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3327207Medicaid
VAVVD142BMedicare PIN
TN3327207Medicare ID - Type Unspecified
TN3327207Medicaid
TN103I112992Medicare PIN
VA005291H94Medicare ID - Type Unspecified
TN103I114457Medicare PIN