Provider Demographics
NPI:1699888487
Name:THORNTON, ROCHEL YVETTE (MD)
Entity type:Individual
Prefix:
First Name:ROCHEL
Middle Name:YVETTE
Last Name:THORNTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ROCHEL
Other - Middle Name:YVETTE
Other - Last Name:THORNTON-WALKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1500 E WOODROW WILSON AVE
Mailing Address - Street 2:PRIMARY CARE GREEN CLINIC
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-5116
Mailing Address - Country:US
Mailing Address - Phone:601-362-4471
Mailing Address - Fax:601-368-4089
Practice Address - Street 1:1500 E WOODROW WILSON AVE
Practice Address - Street 2:PRIMARY CARE GREEN CLINIC
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5116
Practice Address - Country:US
Practice Address - Phone:601-362-4471
Practice Address - Fax:601-368-4089
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17054207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09406009Medicaid
MS17054OtherLICENSE NUMBER
MS17054OtherLICENSE NUMBER
MS080003781Medicare ID - Type Unspecified
MSH93280Medicare UPIN