Healthcare Provider Details

I. General information

NPI: 1821184540
Provider Name (Legal Business Name): HETAL P THAKORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 09/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 13TH STREET SUITE 10
AUGUSTA GA
30901
US

IV. Provider business mailing address

811 13TH STREET SUITE 10
AUGUSTA GA
30901
US

V. Phone/Fax

Practice location:
  • Phone: 706-434-1590
  • Fax: 803-279-6001
Mailing address:
  • Phone: 706-434-1590
  • Fax: 803-279-6001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number053556
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number053556
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number053556
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: