Healthcare Provider Details

I. General information

NPI: 1568460962
Provider Name (Legal Business Name): CARROLL WAYNE THORNBURG D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 11/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 S MESA HILLS DR SUITE 1, BLDG. 1
EL PASO TX
79912-5568
US

IV. Provider business mailing address

725 S MESA HILLS DR SUITE 1, BLDG. 1
EL PASO TX
79912-5568
US

V. Phone/Fax

Practice location:
  • Phone: 915-887-3414
  • Fax: 915-585-1682
Mailing address:
  • Phone: 915-887-3414
  • Fax: 915-585-1682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberG9230
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: