Provider Demographics
NPI:1962637926
Name:THEKKEKANDAM, THOMAS JOSEPH (MD, ABFM, CAQSM)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:JOSEPH
Last Name:THEKKEKANDAM
Suffix:
Gender:M
Credentials:MD, ABFM, CAQSM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1004
Mailing Address - Country:US
Mailing Address - Phone:336-832-7000
Mailing Address - Fax:
Practice Address - Street 1:1635 NC HIGHWAY 66 S
Practice Address - Street 2:SUITE 210
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-3854
Practice Address - Country:US
Practice Address - Phone:336-992-1770
Practice Address - Fax:336-992-1776
Is Sole Proprietor?:No
Enumeration Date:2009-05-20
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2012-01709207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCFM2785Medicare UPIN