Healthcare Provider Details

I. General information

NPI: 1891010799
Provider Name (Legal Business Name): SHILPA B THAKER MD LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2010
Last Update Date: 11/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3150 N TENAYA WAY SUITE 225
LAS VEGAS NV
89128-0443
US

IV. Provider business mailing address

3324 CANOE COVE CT
LAS VEGAS NV
89117-6713
US

V. Phone/Fax

Practice location:
  • Phone: 702-558-2111
  • Fax: 702-558-8333
Mailing address:
  • Phone: 702-303-2076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number13297
License Number StateNV

VIII. Authorized Official

Name: LORI ANN LABRECQUE
Title or Position: ACCOUNTS MGR
Credential:
Phone: 702-453-3799