Healthcare Provider Details

I. General information

NPI: 1851397855
Provider Name (Legal Business Name): ROBERT S. THORNTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 10/07/2020
Certification Date: 10/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 LINE AVE
SHREVEPORT LA
71104-2126
US

IV. Provider business mailing address

2121 LINE AVE
SHREVEPORT LA
71104-2126
US

V. Phone/Fax

Practice location:
  • Phone: 318-226-9441
  • Fax: 318-425-3236
Mailing address:
  • Phone: 318-226-9441
  • Fax: 318-425-3236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number03480R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: