Provider Demographics
NPI:1326069741
Name:THORNTON, WILLIAM DERRICK (OD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:DERRICK
Last Name:THORNTON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 BELLEVUE ROAD
Mailing Address - Street 2:18 ERIN OFFICE PARK
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021
Mailing Address - Country:US
Mailing Address - Phone:478-272-5933
Mailing Address - Fax:478-272-4350
Practice Address - Street 1:2400 BELLEVUE ROAD
Practice Address - Street 2:18 ERIN OFFICE PARK
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021
Practice Address - Country:US
Practice Address - Phone:478-272-5933
Practice Address - Fax:478-272-4350
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002129152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100623OtherAVESIS
GA34465OtherOPTICARE
GA907034188AMedicaid
GA907034188BMedicaid
GA966871OtherBLUE CROSS
P00055084OtherRAILROAD MEDICARE
P00055084OtherRAILROAD MEDICARE
GA907034188AMedicaid