Provider Demographics
NPI:1033202809
Name:THETFORD, DAVID (DO)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:THETFORD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 E 16TH ST
Mailing Address - Street 2:
Mailing Address - City:DALHART
Mailing Address - State:TX
Mailing Address - Zip Code:79022-4802
Mailing Address - Country:US
Mailing Address - Phone:806-244-5668
Mailing Address - Fax:806-244-5912
Practice Address - Street 1:275 CASINO DR
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79118-3816
Practice Address - Country:US
Practice Address - Phone:806-884-9943
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5585207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8A5753OtherBLUE CROSS/BLUE SHIELD
TX155206901Medicaid
TX8A3540Medicare PIN
TXG39861Medicare UPIN