Provider Demographics
NPI:1932445566
Name:THURSTON, PAUL BRIAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:BRIAN
Last Name:THURSTON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3165 MCCRORY PL
Mailing Address - Street 2:SUITE 174
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-3771
Mailing Address - Country:US
Mailing Address - Phone:407-423-1234
Mailing Address - Fax:407-517-1040
Practice Address - Street 1:1307 S INTERNATIONAL PKWY STE 1061
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-1412
Practice Address - Country:US
Practice Address - Phone:407-323-1234
Practice Address - Fax:407-936-1696
Is Sole Proprietor?:No
Enumeration Date:2013-01-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO 3556213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008967700Medicaid
FL6507UOtherBC BS PROVIDER #
FLFT3848631OtherDEA
FLHH054ZMedicare PIN