Provider Demographics
NPI:1346294097
Name:THOMPSON, MICHAEL BARTLETT (DPM)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BARTLETT
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3535 30TH AVE
Mailing Address - Street 2:203
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1632
Mailing Address - Country:US
Mailing Address - Phone:262-657-6104
Mailing Address - Fax:262-657-6194
Practice Address - Street 1:3535 30TH AVE
Practice Address - Street 2:203
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1632
Practice Address - Country:US
Practice Address - Phone:262-657-6104
Practice Address - Fax:262-657-6194
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI343213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000046034OtherPTAN
WI43208600Medicaid
T63511Medicare UPIN
WI6066690001Medicare NSC
WI14171411227Medicare PIN
WI43208600Medicaid