Provider Demographics
NPI:1194788315
Name:THECKEDATH, BOBY G (MD)
Entity type:Individual
Prefix:DR
First Name:BOBY
Middle Name:G
Last Name:THECKEDATH
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 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:262-884-4000
Mailing Address - Fax:262-884-4177
Practice Address - Street 1:8400 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-3735
Practice Address - Country:US
Practice Address - Phone:262-884-4000
Practice Address - Fax:262-884-4177
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38387207RE0101X
WI55991207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100216167Medicaid
KY64096845Medicaid
183441Medicare ID - Type Unspecified
183442Medicare ID - Type Unspecified
5491Medicare ID - Type Unspecified
KY0664903Medicare ID - Type Unspecified
183421Medicare ID - Type Unspecified
183440Medicare ID - Type Unspecified
KY64096845Medicaid
183438Medicare ID - Type Unspecified
5490Medicare ID - Type Unspecified
8001Medicare ID - Type Unspecified
183437Medicare ID - Type Unspecified
KYP00191779Medicare PIN
8577Medicare ID - Type Unspecified