Provider Demographics
NPI:1386658250
Name:THOMPSON, BRENDA J (MEDICAL DOCTOR)
Entity Type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:J
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:MEDICAL DOCTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 W 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46402-1703
Mailing Address - Country:US
Mailing Address - Phone:219-880-1190
Mailing Address - Fax:219-880-0784
Practice Address - Street 1:1021 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46402-1703
Practice Address - Country:US
Practice Address - Phone:219-880-1190
Practice Address - Fax:219-880-0784
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036047737208000000X
IN010280532080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100167580AMedicaid
IN100167580AMedicaid