Provider Demographics
NPI:1336456722
Name:THAXTON, REBECCA (MD)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:
Last Name:THAXTON
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 1:120 CORNWALL LN
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25314-2493
Mailing Address - Country:US
Mailing Address - Phone:304-205-4719
Mailing Address - Fax:304-205-4719
Practice Address - Street 1:120 CORNWALL LN
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25314-2493
Practice Address - Country:US
Practice Address - Phone:304-205-4719
Practice Address - Fax:304-205-4719
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-07
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19163208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice