Provider Demographics
NPI:1003854274
Name:THACKER, STEPHEN W (DO)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:W
Last Name:THACKER
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:PO BOX 51238
Mailing Address - Street 2:ATTENTION: MAGGIE NOLES
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-5538
Mailing Address - Country:US
Mailing Address - Phone:562-741-4461
Mailing Address - Fax:562-741-4413
Practice Address - Street 1:340 W CENTRAL AVE STE 110
Practice Address - Street 2:ATTENTION: MAGGIE NOLES
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-3006
Practice Address - Country:US
Practice Address - Phone:714-529-3971
Practice Address - Fax:714-529-1070
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2007-07-16
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Provider Licenses
StateLicense IDTaxonomies
CA20A5071207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX50710Medicaid
CA00AX50710Medicaid
CAW20A5071FMedicare PIN