Provider Demographics
NPI:1194826743
Name:THURSTON, CANDACE S (MD)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:S
Last Name:THURSTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 TOWN CENTER PKWY
Mailing Address - Street 2:SUITE 309
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-3219
Mailing Address - Country:US
Mailing Address - Phone:703-834-1072
Mailing Address - Fax:703-834-6508
Practice Address - Street 1:1850 TOWN CENTER PKWY
Practice Address - Street 2:SUITE 309
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-3219
Practice Address - Country:US
Practice Address - Phone:703-834-1072
Practice Address - Fax:703-834-6508
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101035311174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAB93577Medicare UPIN
VA015167W97Medicare ID - Type Unspecified