Healthcare Provider Details

I. General information

NPI: 1649291568
Provider Name (Legal Business Name): PUSHPA T. THAKARAR M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 MADISON DR
MALVERN PA
19355-3101
US

IV. Provider business mailing address

902 MADISON DR
MALVERN PA
19355-3101
US

V. Phone/Fax

Practice location:
  • Phone: 610-647-0591
  • Fax: 610-647-2448
Mailing address:
  • Phone: 610-647-0591
  • Fax: 610-647-2448

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberMD-018899-E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: