Provider Demographics
NPI:1104928282
Name:THORNTON, JONATHAN CEDRIC (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:CEDRIC
Last Name:THORNTON
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 1:6499 38TH AVE N
Mailing Address - Street 2:SUITE B-2
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-1656
Mailing Address - Country:US
Mailing Address - Phone:727-347-6635
Mailing Address - Fax:727-343-0913
Practice Address - Street 1:6499 38TH AVE N
Practice Address - Street 2:SUITE B-2
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-1656
Practice Address - Country:US
Practice Address - Phone:727-347-6635
Practice Address - Fax:727-343-0913
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL50125207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL02910Medicare ID - Type Unspecified
FLD84747Medicare UPIN