Healthcare Provider Details

I. General information

NPI: 1790911972
Provider Name (Legal Business Name): TODD ELLIOTT THURSTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2009
Last Update Date: 05/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

979 E 3RD ST STE C920
CHATTANOOGA TN
37403-2136
US

IV. Provider business mailing address

979 E 3RD ST STE C920
CHATTANOOGA TN
37403-2136
US

V. Phone/Fax

Practice location:
  • Phone: 423-756-7134
  • Fax: 423-763-4571
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301108131
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberMD0000055433
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberMD0000055433
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: