MEDICARE: NIMISH THAKER 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	174400000X	Specialist	A747570	CA
2	208800000X	Urology Physician	A74757	CA

General Provider Information

NPI Number	:	1871541961
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NIMISH THAKER MD

Provider Business Mailing Address
First Line	:	1791 E HOLT BLVD UNIT 101
Second Line	:
City	:	ONTARIO
State	:	CA
Zip	:	91761-2118
Country	:	US
Telephone Number	:	909-460-0354
Fax Number	:	909-460-0367

Provider Business Practice Location Address
First Line	:	1791 E HOLT BLVD UNIT 101
Second Line	:
City	:	ONTARIO
State	:	CA
Zip	:	91761-2118
Country	:	US
Telephone Number	:	909-460-0354
Fax Number	:	909-460-0367

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

Provider Enumeration Date	:	05/04/2006
Last Update Date	:	05/06/2024

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