Healthcare Provider Details

I. General information

NPI: 1710979000
Provider Name (Legal Business Name): GNAN N THAKORE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 12/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 E APPLE ST STE 5254A
DAYTON OH
45409
US

IV. Provider business mailing address

3170 KETTERING BLVD BLDG B3
MORAINE OH
45439-1924
US

V. Phone/Fax

Practice location:
  • Phone: 937-208-4200
  • Fax: 937-208-4205
Mailing address:
  • Phone: 937-991-3188
  • Fax: 937-223-9811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number35067458
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: