Provider Demographics
NPI:1437145687
Name:THURDEKOOS, PAUL (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:THURDEKOOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 PROFESSIONAL PARK DR
Mailing Address - Street 2:SUITE 31
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6529
Mailing Address - Country:US
Mailing Address - Phone:423-975-5650
Mailing Address - Fax:423-975-5652
Practice Address - Street 1:3 PROFESSIONAL PARK DR
Practice Address - Street 2:SUITE 31
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6529
Practice Address - Country:US
Practice Address - Phone:423-975-5650
Practice Address - Fax:423-975-5652
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD12981208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3184779Medicaid
TNB04151Medicare UPIN
TN3184779Medicaid