Provider Demographics
NPI:1437240603
Name:STURDAVANT, THOMAS E (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:E
Last Name:STURDAVANT
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:PO BOX 416
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37662-0416
Mailing Address - Country:US
Mailing Address - Phone:423-246-7240
Mailing Address - Fax:
Practice Address - Street 1:113 CASSELL DR
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660
Practice Address - Country:US
Practice Address - Phone:423-246-7240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16798208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS16798OtherSTATE LICENSE #
MS00122797Medicaid
H22786Medicare UPIN
MS16798OtherSTATE LICENSE #