Provider Demographics
NPI:1659336733
Name:THOMPSON, MATTHEW J (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
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 1:1087 W MASON ST
Mailing Address - Street 2:#1
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-1859
Mailing Address - Country:US
Mailing Address - Phone:920-499-3102
Mailing Address - Fax:920-499-9636
Practice Address - Street 1:1087 W MASON ST
Practice Address - Street 2:#1
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-1859
Practice Address - Country:US
Practice Address - Phone:920-499-3102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036117608207W00000X
WI53859-020207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036117608Medicaid
ILP00404391OtherRR MEDICARE
WI1659336733Medicaid
IL036117608Medicaid