Provider Demographics
NPI:1114920261
Name:THACKER, RICHARD RANDALL (DO)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:RANDALL
Last Name:THACKER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2770 CAPITAL MEDICAL BLVD
Mailing Address - Street 2:STE 200
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-8417
Mailing Address - Country:US
Mailing Address - Phone:850-878-8235
Mailing Address - Fax:850-219-2373
Practice Address - Street 1:2770 CAPITAL MEDICAL BLVD
Practice Address - Street 2:STE 200
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-8417
Practice Address - Country:US
Practice Address - Phone:850-878-8235
Practice Address - Fax:850-219-2373
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2016-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMEOS6976207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL058464900OtherMEDICAID GROUP
FL57188OtherINDIVIDUAL PROVIDER BCBS
FL99039OtherGROUP BCBS ID NUMBER
FL37822101Medicaid
FLP00625814OtherMEDICARE RAILROAD
GA1114920261Medicaid
FL37822101Medicaid
FL37822101Medicaid