Provider Demographics
NPI:1053455345
Name:THACKER, SUNIL R (MD)
Entity Type:Individual
Prefix:
First Name:SUNIL
Middle Name:R
Last Name:THACKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 EAGLE AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OCEAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07712-7631
Mailing Address - Country:US
Mailing Address - Phone:732-660-6200
Mailing Address - Fax:732-775-6142
Practice Address - Street 1:1200 EAGLE AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:OCEAN
Practice Address - State:NJ
Practice Address - Zip Code:07712
Practice Address - Country:US
Practice Address - Phone:732-660-6200
Practice Address - Fax:732-775-6142
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07218400174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ20023925OtherRAILROAD MEDICARE
NJ20023925OtherRAILROAD MEDICARE
NJ080708Medicare ID - Type Unspecified