Provider Demographics
NPI:1639368764
Name:CARROLL W. THORNBURG D.O.,P.A.
Entity Type:Organization
Organization Name:CARROLL W. THORNBURG D.O.,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARROLL
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:THORNBURG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:915-842-0990
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2016-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG9230207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX130974208Medicaid
NME0068Medicaid
TX130974207Medicaid
TX130974210Medicaid
TX00276ZMedicare PIN
TX0073QJOtherBLUECROSS BLUESHIELD
TX130974209Medicaid
TX177486102Medicaid
NM300521076Medicare PIN
TXWA003OtherTRICARE
TX177486101Medicaid
NM00H10XMedicare PIN
TX8F0807Medicare PIN
TXA67734OtherUPIN #
TX177486103Medicaid
NM201013584Medicaid