Provider Demographics
NPI:1770591141
Name:THOMPSON, WENDY (MD)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
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 12427
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32317-2427
Mailing Address - Country:US
Mailing Address - Phone:850-297-0114
Mailing Address - Fax:850-297-2020
Practice Address - Street 1:2858 MAHAN DR
Practice Address - Street 2:SUITE 5
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5446
Practice Address - Country:US
Practice Address - Phone:850-942-0180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME46806207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL041872200Medicaid
D46330Medicare UPIN
FLO5966XMedicare PIN