Healthcare Provider Details

I. General information

NPI: 1629058169
Provider Name (Legal Business Name): AMINIDHAN D THAKKAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 06/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 N HIGHWAY 377 STE 119
ROANOKE TX
76262-6916
US

IV. Provider business mailing address

1212 N HIGHWAY 377 STE 119
ROANOKE TX
76262-6916
US

V. Phone/Fax

Practice location:
  • Phone: 682-831-1591
  • Fax:
Mailing address:
  • Phone: 682-831-1591
  • Fax: 682-831-1598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberK8519
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: