Provider Demographics
NPI:1851397855
Name:THORNTON, ROBERT S (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:S
Last Name:THORNTON
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 1:2121 LINE AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-2126
Mailing Address - Country:US
Mailing Address - Phone:318-226-9441
Mailing Address - Fax:318-425-3236
Practice Address - Street 1:2121 LINE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-2126
Practice Address - Country:US
Practice Address - Phone:318-226-9441
Practice Address - Fax:318-425-3236
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA03480R207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1171662Medicaid
B60975Medicare UPIN
LA5K646Medicare ID - Type Unspecified