Provider Demographics
NPI:1831158278
Name:THORNTON, STACEY L (MD)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:L
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 1:5012 S US HIGHWAY 75 STE 300
Mailing Address - Street 2:ATT: BILLING
Mailing Address - City:DENISON
Mailing Address - State:TX
Mailing Address - Zip Code:75020-4589
Mailing Address - Country:US
Mailing Address - Phone:903-416-6430
Mailing Address - Fax:
Practice Address - Street 1:5012 S US HIGHWAY 75 STE 250
Practice Address - Street 2:
Practice Address - City:DENISON
Practice Address - State:TX
Practice Address - Zip Code:75020-4587
Practice Address - Country:US
Practice Address - Phone:903-416-6430
Practice Address - Fax:903-416-6431
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4560207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0393514-01Medicaid
TX039351402Medicaid
OK200192830AMedicaid
TX329504YMCMMedicare PIN
TX039351402Medicaid