Provider Demographics
NPI:1417920828
Name:THOMPSON, MELANIE M (MD)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:M
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4425 N PORT WASHINGTON RD
Mailing Address - Street 2:ATTN: CSMCP CLINC CREDENTIALING
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-1082
Mailing Address - Country:US
Mailing Address - Phone:262-377-6933
Mailing Address - Fax:262-376-2495
Practice Address - Street 1:N143W6515 PIONEER RD
Practice Address - Street 2:
Practice Address - City:CEDARBURG
Practice Address - State:WI
Practice Address - Zip Code:53012-2705
Practice Address - Country:US
Practice Address - Phone:262-377-6933
Practice Address - Fax:262-376-2495
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI38132207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32475300Medicaid
WIG79530Medicare UPIN