Provider Demographics
NPI:1225120454
Name:THORSON, JOHN A (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:A
Last Name:THORSON
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W ARBOR DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-9001
Mailing Address - Country:US
Mailing Address - Phone:619-543-7874
Mailing Address - Fax:
Practice Address - Street 1:200 W ARBOR DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-9001
Practice Address - Country:US
Practice Address - Phone:619-543-7874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006023097207ZP0007X, 207ZP0105X
MI4301081249207ZP0007X, 207ZP0105X
CAA82079207SM0001X, 207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
No207ZP0007XAllopathic & Osteopathic PhysiciansPathologyMolecular Genetic Pathology
No207SM0001XAllopathic & Osteopathic PhysiciansMedical GeneticsMolecular Genetic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO# PENDINGMedicaid
MI4544083Medicaid
MI0H16101084Medicare ID - Type Unspecified
MO# PENDINGMedicaid
MO# PENDINGMedicare ID - Type UnspecifiedMEDICARE PROV. #
MI4544083Medicaid