Provider Demographics
NPI:1023039948
Name:ENDICOTT, THYRA J (MD)
Entity Type:Individual
Prefix:DR
First Name:THYRA
Middle Name:J
Last Name:ENDICOTT
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 14556
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-8556
Mailing Address - Country:US
Mailing Address - Phone:310-517-4785
Mailing Address - Fax:
Practice Address - Street 1:510 N PROSPECT AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-3028
Practice Address - Country:US
Practice Address - Phone:310-517-4785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA613162085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG75175Medicare UPIN
CAWA61316EMedicare PIN
CAWA61316CMedicare PIN