Provider Demographics
NPI:1902842800
Name:THURSTON, JOHN BRADLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BRADLEY
Last Name:THURSTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8330 NAAB RD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-5925
Mailing Address - Country:US
Mailing Address - Phone:317-872-6760
Mailing Address - Fax:317-879-4029
Practice Address - Street 1:8330 NAAB RD
Practice Address - Street 2:SUITE 140
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-5925
Practice Address - Country:US
Practice Address - Phone:317-872-6760
Practice Address - Fax:317-879-4029
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-21
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01024334A208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN4248019OtherAETNA PROVIDER #
IN000000083383OtherBCBS PIN #
IN4248019OtherAETNA PROVIDER #
IN065880AMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER