Provider Demographics
NPI:1922235787
Name:THORNTON, CANDICE A (MD)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:A
Last Name:THORNTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CANDICE
Other - Middle Name:ANN
Other - Last Name:MCKEARIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11402 ANDERSON RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29611-7557
Practice Address - Country:US
Practice Address - Phone:864-631-2799
Practice Address - Fax:864-522-1215
Is Sole Proprietor?:No
Enumeration Date:2009-06-18
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC31842207RA0000X, 208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC318427Medicaid