Provider Demographics
NPI:1568460962
Name:THORNBURG, CARROLL WAYNE (DO)
Entity Type:Individual
Prefix:
First Name:CARROLL
Middle Name:WAYNE
Last Name:THORNBURG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 S MESA HILLS DR
Mailing Address - Street 2:SUITE 1, BLDG. 1
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-5568
Mailing Address - Country:US
Mailing Address - Phone:915-887-3414
Mailing Address - Fax:915-585-1682
Practice Address - Street 1:725 S MESA HILLS DR
Practice Address - Street 2:SUITE 1, BLDG. 1
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-5568
Practice Address - Country:US
Practice Address - Phone:915-887-3414
Practice Address - Fax:915-585-1682
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG9230207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NME0068Medicaid
TX8F0807Medicare ID - Type UnspecifiedMEDICARE TX INDIVIDUAL #
NM300521076Medicare PIN
NME0068Medicaid