Provider Demographics
NPI:1790911972
Name:THURSTON, TODD ELLIOTT (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:ELLIOTT
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 1:979 E 3RD ST
Mailing Address - Street 2:STE C920
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37403-2136
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:979 E 3RD ST
Practice Address - Street 2:STE C920
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2136
Practice Address - Country:US
Practice Address - Phone:423-756-7134
Practice Address - Fax:423-763-4571
Is Sole Proprietor?:No
Enumeration Date:2009-06-02
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301108131390200000X
TNMD00000554332086S0122X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ027474Medicaid