Healthcare Provider Details

I. General information

NPI: 1962637926
Provider Name (Legal Business Name): THOMAS JOSEPH THEKKEKANDAM M.D., ABFM, CAQSM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2009
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 N CHURCH ST
GREENSBORO NC
27401-1038
US

IV. Provider business mailing address

PO BOX 5105
BELFAST ME
04915-5100
US

V. Phone/Fax

Practice location:
  • Phone: 336-375-2300
  • Fax: 336-375-2314
Mailing address:
  • Phone: 336-375-2300
  • Fax: 336-375-2314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number2012-01709
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: