MEDICARE: DR. AMINIDHAN D THAKKAR MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	K8519	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	930078750	OTHER	TX	MEDICARE RAILROAD
4	930095584	OTHER	TX	MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	86796N	OTHER	TX	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	85154Y	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1629058169
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AMINIDHAN D THAKKAR MD

Provider Business Mailing Address
First Line	:	1212 N HIGHWAY 377 STE 119
Second Line	:
City	:	ROANOKE
State	:	TX
Zip	:	76262-6916
Country	:	US
Telephone Number	:	682-831-1591
Fax Number	:	682-831-1598

Provider Business Practice Location Address
First Line	:	1212 N HIGHWAY 377 STE 119
Second Line	:
City	:	ROANOKE
State	:	TX
Zip	:	76262-6916
Country	:	US
Telephone Number	:	682-831-1591
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/19/2006
Last Update Date	:	06/10/2013

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