Healthcare Provider Details

I. General information

NPI: 1477998532
Provider Name (Legal Business Name): JAI DEEP THAKUR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2013
Last Update Date: 10/07/2020
Certification Date: 10/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 CENTER ST
MOBILE AL
36604-1541
US

IV. Provider business mailing address

PO BOX 40480
MOBILE AL
36640-0480
US

V. Phone/Fax

Practice location:
  • Phone: 516-605-5108
  • Fax: 251-660-5792
Mailing address:
  • Phone: 251-434-3626
  • Fax: 251-445-2464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberMD.40438
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: