Provider Demographics
NPI:1851399364
Name:THORSTENSON, LYLE SHELDON (M D)
Entity type:Individual
Prefix:DR
First Name:LYLE
Middle Name:SHELDON
Last Name:THORSTENSON
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-5347
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4500 S LANCASTER RD STE 112C
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75216-7167
Practice Address - Country:US
Practice Address - Phone:214-857-1441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF2064207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F2997OtherMEDICARE
TXHH69OtherBLUE CROSS BLUE SHIELD
TX033864201Medicaid
TX033864202Medicaid
TXP000HH693Medicaid
TX00HH69 / 451159Medicare ID - Type Unspecified
TX8F2997OtherMEDICARE