Provider Demographics
NPI:1013955210
Name:THOMPSON, TERRY L (MD)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:L
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:PO BOX 171206
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38187-1206
Mailing Address - Country:US
Mailing Address - Phone:901-765-3212
Mailing Address - Fax:901-765-3212
Practice Address - Street 1:5959 PARK AVE
Practice Address - Street 2:RADIOLOGY DEPARTMENT
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-5200
Practice Address - Country:US
Practice Address - Phone:901-765-3212
Practice Address - Fax:901-765-3212
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0077452085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00115949Medicaid
TN3036174Medicaid
E10777Medicare UPIN
TN3036174Medicaid