Healthcare Provider Details

I. General information

NPI: 1679502538
Provider Name (Legal Business Name): BRETT MCKINNEY THACKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 11/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 FERRIS AVENUE SUITE I
WAXAHACHIE TX
75165
US

IV. Provider business mailing address

201 FERRIS AVE STE I
WAXAHACHIE TX
75165-3660
US

V. Phone/Fax

Practice location:
  • Phone: 972-937-1613
  • Fax: 972-923-7190
Mailing address:
  • Phone: 972-937-1613
  • Fax: 972-923-7190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG0195
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: