Provider Demographics
NPI:1003975954
Name:THRASHER, BRENTON DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENTON
Middle Name:DAVID
Last Name:THRASHER
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 1:811 S J ST
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33460-5043
Mailing Address - Country:US
Mailing Address - Phone:561-200-9944
Mailing Address - Fax:561-200-9944
Practice Address - Street 1:811 S J ST
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33460-5043
Practice Address - Country:US
Practice Address - Phone:561-200-9944
Practice Address - Fax:561-200-9944
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2011-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME77922207RA0401X, 207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1275846800OtherGROUP NPI
FL46787YOtherMEDICARE PTAN
FL46787YOtherMEDICARE PTAN