Provider Demographics
NPI:1093804395
Name:THURSTON, TIMOTHY (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:THURSTON
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 1:232 ASSOCIATES BLVD
Mailing Address - Street 2:
Mailing Address - City:ALCOA
Mailing Address - State:TN
Mailing Address - Zip Code:37701-1943
Mailing Address - Country:US
Mailing Address - Phone:865-982-7396
Mailing Address - Fax:
Practice Address - Street 1:232 ASSOCIATES BLVD
Practice Address - Street 2:
Practice Address - City:ALCOA
Practice Address - State:TN
Practice Address - Zip Code:37701-1943
Practice Address - Country:US
Practice Address - Phone:865-982-7396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD7497208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3157157Medicaid
TN3157157Medicaid