Basic Information
| Provider Information | |||||||||
| NPI: | 1083874929 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THURSTON | ||||||||
| FirstName: | CARLA | ||||||||
| MiddleName: | TAYLOR | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TAYLOR | ||||||||
| OtherFirstName: | CARLA | ||||||||
| OtherMiddleName: | MARIA | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1990 INDUSTRIAL BLVD | ||||||||
| Address2: | |||||||||
| City: | HOUMA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703637055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858689300 | ||||||||
| FaxNumber: | 9858510053 | ||||||||
| Practice Location | |||||||||
| Address1: | 1302 LAKEWOOD DR STE 202 | ||||||||
| Address2: | |||||||||
| City: | MORGAN CITY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703801883 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9853005438 | ||||||||
| FaxNumber: | 9853801029 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2008 | ||||||||
| LastUpdateDate: | 09/14/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 204579 | LA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1112763 | 05 | LA | MEDICAID | 4Q332CG71 | 01 | MEDICARE PTAN | OTHER |