Provider Demographics
NPI:1063638443
Name:KELLY G THORSTAD MD PA
Entity Type:Organization
Organization Name:KELLY G THORSTAD MD PA
Other - Org Name:LONE STAR PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:G
Authorized Official - Last Name:THORSTAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-833-7334
Mailing Address - Street 1:12120 RANCH ROAD 620 N
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78750-1079
Mailing Address - Country:US
Mailing Address - Phone:512-833-7334
Mailing Address - Fax:512-833-7333
Practice Address - Street 1:12120 RANCH ROAD 620 N
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78750-1079
Practice Address - Country:US
Practice Address - Phone:512-833-7334
Practice Address - Fax:512-833-7333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0651208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty