Healthcare Provider Details

I. General information

NPI: 1902842800
Provider Name (Legal Business Name): JOHN BRADLEY THURSTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 07/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8330 NAAB RD SUITE 140
INDIANAPOLIS IN
46260-5925
US

IV. Provider business mailing address

8330 NAAB RD SUITE 140
INDIANAPOLIS IN
46260-5925
US

V. Phone/Fax

Practice location:
  • Phone: 317-872-6760
  • Fax: 317-879-4029
Mailing address:
  • Phone: 317-872-6760
  • Fax: 317-879-4029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number01024334A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: