Provider Demographics
NPI:1225271513
Name:THORNTON, BLAKELY NELSON
Entity Type:Individual
Prefix:
First Name:BLAKELY
Middle Name:NELSON
Last Name:THORNTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 LINE AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-2126
Mailing Address - Country:US
Mailing Address - Phone:318-226-9441
Mailing Address - Fax:318-425-3236
Practice Address - Street 1:2121 LINE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-2126
Practice Address - Country:US
Practice Address - Phone:318-226-9441
Practice Address - Fax:318-425-3236
Is Sole Proprietor?:No
Enumeration Date:2009-04-15
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA207985207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology