Provider Demographics
NPI:1548336506
Name:THORNTON, MOSE CLINTON (DPM)
Entity type:Individual
Prefix:DR
First Name:MOSE
Middle Name:CLINTON
Last Name:THORNTON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:DR
Other - First Name:M.
Other - Middle Name:CLINT
Other - Last Name:THORNTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPM
Mailing Address - Street 1:401 29TH ST STE 202
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3581
Mailing Address - Country:US
Mailing Address - Phone:510-835-3338
Mailing Address - Fax:510-835-2127
Practice Address - Street 1:401 29TH ST STE 202
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3581
Practice Address - Country:US
Practice Address - Phone:510-835-3338
Practice Address - Fax:510-835-2127
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3553213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E35532Medicare PIN