Healthcare Provider Details

I. General information

NPI: 1396737037
Provider Name (Legal Business Name): PANKAJ D THAKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 02/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 E HARDING WAY SUITE I
STOCKTON CA
95204-6118
US

IV. Provider business mailing address

415 E HARDING WAY SUITE I
STOCKTON CA
95204-6118
US

V. Phone/Fax

Practice location:
  • Phone: 209-467-1001
  • Fax: 209-467-1005
Mailing address:
  • Phone: 209-467-1001
  • Fax: 209-467-1005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberC52146
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberC52146
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: