Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 20A5071 | CA |
NPI | 1003854274 |
---|---|
Provider Name | Dr. Stephen W. Thacker |
First Address | Los Angeles, CA 90051-5538 |
Second Address | Brea, CA 92821-3006 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/06/2006 |
Last Update Date | 16/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00AX50710 | (05) | CA |
A93608 | (02) |