Provider Demographics
NPI:1083671689
Name:THROCKMORTON, TOM DUDLEY (MD)
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:DUDLEY
Last Name:THROCKMORTON
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 1:1307 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:IA
Mailing Address - Zip Code:51301-3066
Mailing Address - Country:US
Mailing Address - Phone:712-262-8385
Mailing Address - Fax:
Practice Address - Street 1:1823 HIGHWAY BLVD
Practice Address - Street 2:SUITE 5
Practice Address - City:SPENCER
Practice Address - State:IA
Practice Address - Zip Code:51301-2226
Practice Address - Country:US
Practice Address - Phone:712-262-6320
Practice Address - Fax:712-264-3007
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA18439208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0153700Medicaid
IAA01344Medicare UPIN
IA0153700Medicaid