Provider Demographics
NPI:1467455071
Name:THORNBERRY, ROBERT L (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:THORNBERRY
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 1:3334 CAPITAL MEDICAL BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4470
Mailing Address - Country:US
Mailing Address - Phone:850-877-8174
Mailing Address - Fax:850-877-5636
Practice Address - Street 1:3334 CAPITAL MEDICAL BLVD
Practice Address - Street 2:STE 400
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4470
Practice Address - Country:US
Practice Address - Phone:850-877-8174
Practice Address - Fax:850-877-5636
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME42261207X00000X
GA026040207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000354186AMedicaid
FL067592000Medicaid
FL37447XMedicare ID - Type UnspecifiedTALLAHASSEE
FL37447UMedicare ID - Type UnspecifiedPERRY
GA000354186AMedicaid
FL067592000Medicaid