Healthcare Provider Details

I. General information

NPI: 1578900809
Provider Name (Legal Business Name): SANDEEP K. THAKKAR, D.O.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2013
Last Update Date: 05/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 SUPERIOR AVE STE. 200A
NEWPORT BEACH CA
92663-3663
US

IV. Provider business mailing address

510 SUPERIOR AVE STE. 200A
NEWPORT BEACH CA
92663-3663
US

V. Phone/Fax

Practice location:
  • Phone: 562-233-9109
  • Fax: 949-650-4585
Mailing address:
  • Phone: 562-233-9109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License Number20A10840
License Number StateCA

VIII. Authorized Official

Name: SANDEEP K THAKKAR
Title or Position: OWNER
Credential: D.O.
Phone: 562-233-9109