Healthcare Provider Details

I. General information

NPI: 1003854274
Provider Name (Legal Business Name): STEPHEN W. THACKER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 W CENTRAL AVE STE 110 ATTENTION: MAGGIE NOLES
BREA CA
92821-3006
US

IV. Provider business mailing address

PO BOX 51238 ATTENTION: MAGGIE NOLES
LOS ANGELES CA
90051-5538
US

V. Phone/Fax

Practice location:
  • Phone: 714-529-3971
  • Fax: 714-529-1070
Mailing address:
  • Phone: 562-741-4461
  • Fax: 562-741-4413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A5071
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: