Provider Demographics
NPI:1356346514
Name:THAXTON, LORA LEE (MD)
Entity type:Individual
Prefix:
First Name:LORA
Middle Name:LEE
Last Name:THAXTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3361 TRULUCK PL
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:FL
Mailing Address - Zip Code:34484-3493
Mailing Address - Country:US
Mailing Address - Phone:419-356-4767
Mailing Address - Fax:
Practice Address - Street 1:1451 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32159
Practice Address - Country:US
Practice Address - Phone:352-751-8506
Practice Address - Fax:352-751-8516
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME139140208100000X
OH35071671T208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2254715Medicaid
OHTH4048995Medicare PIN
OHH01042Medicare UPIN