=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063504264
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | OLIVER SCHOONMAKER THRESHER JR. MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2006
-----------------------------------------------------
Last Update Date | 06/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 HYGEIA DR
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19713-2049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-273-1701
-----------------------------------------------------
Fax | 302-273-4497
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 HYGEIA DR
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19713-2049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-273-1701
-----------------------------------------------------
Fax | 302-273-4497
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | D0033925
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | C1-0002783
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------