Healthcare Provider Details

I. General information

NPI: 1003975954
Provider Name (Legal Business Name): BRENTON DAVID THRASHER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2006
Last Update Date: 08/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 S J ST
LAKE WORTH FL
33460-5043
US

IV. Provider business mailing address

811 S J ST
LAKE WORTH FL
33460-5043
US

V. Phone/Fax

Practice location:
  • Phone: 561-200-9944
  • Fax: 561-200-9944
Mailing address:
  • Phone: 561-200-9944
  • Fax: 561-200-9944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License NumberME77922
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License NumberME77922
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: