Provider Demographics
NPI:1528373503
Name:THOMPSON, TERRY M (CO)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:M
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:CO
Other - Prefix:
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Mailing Address - Street 1:PO BOX 24905
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27114-4905
Mailing Address - Country:US
Mailing Address - Phone:336-397-2165
Mailing Address - Fax:336-397-2167
Practice Address - Street 1:3672 MARATHON CIR
Practice Address - Street 2:SUITE 140
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-6821
Practice Address - Country:US
Practice Address - Phone:678-738-7380
Practice Address - Fax:678-738-7382
Is Sole Proprietor?:No
Enumeration Date:2010-08-13
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA49222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO 003087OtherAMERICAN BOARD FOR CERTIFICATION IN ORTHOTICS & PROSTHETICS
GA49OtherCOMPOSITE STATE BOARD OF MEDICAL EXAMINERS OF GA