Provider Demographics
NPI:1477564789
Name:THURSTON, MICHELE L (MD)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:L
Last Name:THURSTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:L
Other - Last Name:STONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1355 MARINERS DR
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46582-7145
Practice Address - Country:US
Practice Address - Phone:574-267-6778
Practice Address - Fax:574-267-3134
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061461A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200956680Medicaid
IN000000655778OtherANTHEM
IN200825560Medicaid
INM100019232Medicare PIN
3070800LMedicare PIN
IN000000655778OtherANTHEM
IN200956680Medicaid