Provider Demographics
NPI:1255374492
Name:THEAKSTON, ROBERT W (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:W
Last Name:THEAKSTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 GREENHILL BLVD NW
Mailing Address - Street 2:
Mailing Address - City:FORT PAYNE
Mailing Address - State:AL
Mailing Address - Zip Code:35967-3755
Mailing Address - Country:US
Mailing Address - Phone:256-845-9355
Mailing Address - Fax:256-845-7824
Practice Address - Street 1:211 GREENHILL BLVD NW
Practice Address - Street 2:
Practice Address - City:FORT PAYNE
Practice Address - State:AL
Practice Address - Zip Code:35967-3755
Practice Address - Country:US
Practice Address - Phone:256-845-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL19991207P00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009932309Medicaid
AL051556488THEMedicare ID - Type Unspecified
AL009932309Medicaid