1629120456 NPI number — DR. MICHAEL DOUGLAS THURN O.D.

Table of content: DR. MICHAEL DOUGLAS THURN O.D. (NPI 1629120456)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629120456 NPI number — DR. MICHAEL DOUGLAS THURN O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THURN
Provider First Name:
MICHAEL
Provider Middle Name:
DOUGLAS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629120456
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/26/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3101 PGA BLVD
Provider Second Line Business Mailing Address:
SUITE A101
Provider Business Mailing Address City Name:
PALM BEACH GARDENS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33410-2820
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-627-8185
Provider Business Mailing Address Fax Number:
561-627-6456

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3101 PGA BLVD
Provider Second Line Business Practice Location Address:
SUITE A101
Provider Business Practice Location Address City Name:
PALM BEACH GARDENS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33410-2820
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-627-8185
Provider Business Practice Location Address Fax Number:
561-627-6456
Provider Enumeration Date:
01/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPC 2131 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: OPC 2131 . This is a "STATE LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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