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1437151453

NPI Code Detail

MEDICARE: DR. JONATHAN DAVID THACKERAY MD

MEDICARE: DR. JONATHAN DAVID THACKERAY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	35.083628	OH
2	2080C0008X	Child Abuse Pediatrics Physician	35.083628	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1437151453
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN DAVID THACKERAY MD

Provider Business Mailing Address
First Line	:	PO BOX 933432
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44193-0039
Country	:	US
Telephone Number	:	937-641-3000
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 CHILDRENS PLZ
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45404-1815
Country	:	US
Telephone Number	:	937-641-4000
Fax Number	:	937-641-3918

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/10/2005
Last Update Date	:	10/12/2023

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Directions to “ DR. JONATHAN DAVID THACKERAY MD” Practice Location

Language	Start Address	Practice Location

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