Provider Demographics
NPI:1326069741
Name:THORNTON, WILLIAM DERRICK (OD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:DERRICK
Last Name:THORNTON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2282 E PINETREE BLVD
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-4807
Mailing Address - Country:US
Mailing Address - Phone:229-226-6000
Mailing Address - Fax:229-226-5859
Practice Address - Street 1:2375 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6517
Practice Address - Country:US
Practice Address - Phone:229-875-2020
Practice Address - Fax:229-890-7741
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002129152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00055084OtherRAILROAD MEDICARE
GA966871OtherBLUE CROSS
GA907034188AMedicaid
GA34465OtherOPTICARE
GA907034188BMedicaid
GA100623OtherAVESIS
P00055084OtherRAILROAD MEDICARE
GA907034188AMedicaid