Basic Information
| Provider Information | |||||||||
| NPI: | 1700883485 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOBURN | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | KIRK | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 918025 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328918025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522650291 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1600 SW ARCHER RD | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326103003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522650291 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 10/13/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | ME0057091 | FL | N | Allopathic & Osteopathic Physicians | Surgery | 2085R0202X | ME0057091 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085U0001X | ME0057091 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085B0100X | ME0057091 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085D0003X | ME0057091 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Neuroimaging | 2085N0904X | ME0057091 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085P0229X | ME0057091 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085N0700X | ME0057091 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0203X | ME0057091 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Therapeutic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 002668700 | 05 | FL | MEDICAID |