Provider Demographics
NPI:1750452421
Name:THURSTON, CHARLES S (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:S
Last Name:THURSTON
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 1:343 W HOUSTON STREET
Mailing Address - Street 2:SUITE 909
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78205
Mailing Address - Country:US
Mailing Address - Phone:210-222-0376
Mailing Address - Fax:210-222-9198
Practice Address - Street 1:343 W HOUSTON STREET
Practice Address - Street 2:SUITE 909
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78205
Practice Address - Country:US
Practice Address - Phone:210-222-0376
Practice Address - Fax:210-222-9198
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE5965207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B26979Medicare UPIN
TX00AM02Medicare ID - Type Unspecified