Provider Demographics
NPI:1083653489
Name:THORNFELDT, CARL R (MD)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:R
Last Name:THORNFELDT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 NW 12TH ST
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-2268
Mailing Address - Country:US
Mailing Address - Phone:208-452-7450
Mailing Address - Fax:208-452-7550
Practice Address - Street 1:811 NW 12TH ST
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2268
Practice Address - Country:US
Practice Address - Phone:208-452-7450
Practice Address - Fax:208-452-7550
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7442207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C91195Medicare UPIN