Healthcare Provider Details

I. General information

NPI: 1619137544
Provider Name (Legal Business Name): VISHAL THAKRAL D.O., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2008
Last Update Date: 12/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 S BEVERLY DR SUITE 720
LOS ANGELES CA
90035-1148
US

IV. Provider business mailing address

1125 S BEVERLY DR SUITE 720
LOS ANGELES CA
90035-1148
US

V. Phone/Fax

Practice location:
  • Phone: 310-929-9790
  • Fax: 310-929-9791
Mailing address:
  • Phone: 310-929-9790
  • Fax: 310-929-9791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number20A12362
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: