Provider Demographics
NPI:1740533769
Name:THORNE, JACK L (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:L
Last Name:THORNE
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:PO BOX 524
Mailing Address - Street 2:
Mailing Address - City:GRAND LAKE
Mailing Address - State:CO
Mailing Address - Zip Code:80447-0524
Mailing Address - Country:US
Mailing Address - Phone:970-531-0284
Mailing Address - Fax:
Practice Address - Street 1:124 COUNTRY ROAD 4955
Practice Address - Street 2:
Practice Address - City:GRAND LAKE
Practice Address - State:CO
Practice Address - Zip Code:80447-0524
Practice Address - Country:US
Practice Address - Phone:970-531-0284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-16
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO15603207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology