Healthcare Provider Details

I. General information

NPI: 1003978271
Provider Name (Legal Business Name): RITA ROOP THAKUR M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 05/10/2023
Certification Date: 05/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

636 E SANTA CLARA ST
SAN JOSE CA
95112-1902
US

IV. Provider business mailing address

460 REVERE TER
FREMONT CA
94539-5976
US

V. Phone/Fax

Practice location:
  • Phone: 408-307-2123
  • Fax:
Mailing address:
  • Phone: 408-307-2123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA43923
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: