=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629546585
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REUBEN I THAKER MD PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2018
-----------------------------------------------------
Last Update Date | 11/08/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9420 W SAHARA AVE STE 105
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89117-8800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-545-0660
-----------------------------------------------------
Fax | 253-461-7851
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9420 W SAHARA AVE STE 105
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89117-8800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-545-0660
-----------------------------------------------------
Fax | 253-461-7851
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | REUBEN THAKER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 702-545-0660
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------