Provider Demographics
NPI:1114983723
Name:THROCKMORTON, JOHN KERSEY (DPM)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:KERSEY
Last Name:THROCKMORTON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:K
Other - Last Name:THROCKMORTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:200 E 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-4358
Mailing Address - Country:US
Mailing Address - Phone:704-874-1904
Mailing Address - Fax:704-865-4614
Practice Address - Street 1:111 E 3RD AVE
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28052-4317
Practice Address - Country:US
Practice Address - Phone:704-874-3300
Practice Address - Fax:704-874-0065
Is Sole Proprietor?:No
Enumeration Date:2006-04-22
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC702213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
5335346OtherBCBS
T33978Medicare UPIN
5335346Medicare ID - Type Unspecified
MI0P36190001Medicare PIN