Provider Demographics
NPI:1659367449
Name:THOMPSON, WILLARD RAY JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLARD
Middle Name:RAY
Last Name:THOMPSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:6035 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3256
Mailing Address - Country:US
Mailing Address - Phone:704-295-3000
Mailing Address - Fax:
Practice Address - Street 1:530 CORPORATE CIR
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28147-8074
Practice Address - Country:US
Practice Address - Phone:704-637-0158
Practice Address - Fax:704-637-7710
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17741174400000X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC02606OtherBCBS PROVIDER ID
NC4412228OtherAETNA
SC30158896OtherSELECT HEALTH OF SC
NCP01259200OtherRAILROAD MEDICARE
SCQ17741Medicaid
NC83198OtherBCBSNC
NC8902606Medicaid
C86759Medicare UPIN
NCNCF351AMedicare PIN
NC4412228OtherAETNA