Healthcare Provider Details

I. General information

NPI: 1275239311
Provider Name (Legal Business Name): RUPA THACKER MD CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2023
Last Update Date: 01/31/2023
Certification Date: 01/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6255 N FRESNO ST STE 106
FRESNO CA
93710-5271
US

IV. Provider business mailing address

2465 E SUMMIT WAY
FRESNO CA
93730-7054
US

V. Phone/Fax

Practice location:
  • Phone: 559-336-4535
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RUPA THACKER
Title or Position: PRESIDENT
Credential: MD
Phone: 559-336-4535