Provider Demographics
NPI:1144593567
Name:THAKUR, MANISH (DO)
Entity Type:Individual
Prefix:DR
First Name:MANISH
Middle Name:
Last Name:THAKUR
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:PO BOX 25180
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97298-0180
Mailing Address - Country:US
Mailing Address - Phone:203-415-1023
Mailing Address - Fax:203-415-0123
Practice Address - Street 1:9205 SW BARNES RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6603
Practice Address - Country:US
Practice Address - Phone:203-415-1023
Practice Address - Fax:203-415-1023
Is Sole Proprietor?:No
Enumeration Date:2012-02-15
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1699632085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR169963OtherOREGON MEDICAL LICENSE DO
OR169963OtherOREGON MEDICAL LICENSE DO