Healthcare Provider Details

I. General information

NPI: 1194704767
Provider Name (Legal Business Name): DAVE H. THACKER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7321 11TH ST 75 MDG/SGOPC
HILL AFB UT
84056-5012
US

IV. Provider business mailing address

5144 VILLAGE WOOD CT
WEST VALLEY CITY UT
84120-4585
US

V. Phone/Fax

Practice location:
  • Phone: 801-777-6804
  • Fax: 801-586-4018
Mailing address:
  • Phone: 801-982-1528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number340105-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: