Healthcare Provider Details

I. General information

NPI: 1255411989
Provider Name (Legal Business Name): JONATHAN L THORNSBERRY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 10/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

363 E. ROUTE 66
STRAFFORD MO
65757
US

IV. Provider business mailing address

PO BOX 505164
SAINT LOUIS MO
63150-5164
US

V. Phone/Fax

Practice location:
  • Phone: 417-736-9175
  • Fax: 417-736-9178
Mailing address:
  • Phone: 417-829-4620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2003014014
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: