Provider Demographics
NPI:1245237171
Name:THORNTON, CHARLES NEAL (MD)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:NEAL
Last Name:THORNTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MR
Other - First Name:CHARLES
Other - Middle Name:NEAL
Other - Last Name:THORNTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:5002 COWHORN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-9766
Mailing Address - Country:US
Mailing Address - Phone:903-614-3000
Mailing Address - Fax:903-614-3525
Practice Address - Street 1:5402 SUMMERHILL RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-4607
Practice Address - Country:US
Practice Address - Phone:903-614-3937
Practice Address - Fax:903-614-3525
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2011-12-02
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
TXG7728207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR89553OtherAR BLUE CROSS
TX81380YOtherTEXAS BLUE CROSS
AR109971001Medicaid
TX81380YOtherTEXAS BLUE CROSS
AR89553OtherAR BLUE CROSS
AR109971001Medicaid