Provider Demographics
NPI:1285680280
Name:NIMSHA THAVER, D.O PC
Entity Type:Organization
Organization Name:NIMSHA THAVER, D.O PC
Other - Org Name:NIMSHA THAVER, D.O.
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NIMSHAVATHANI
Authorized Official - Middle Name:
Authorized Official - Last Name:THAVER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:310-947-9517
Mailing Address - Street 1:53 PASEO DE CASTANA
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-6385
Mailing Address - Country:US
Mailing Address - Phone:310-802-3219
Mailing Address - Fax:310-831-3000
Practice Address - Street 1:1350 W 6TH ST
Practice Address - Street 2:SECOND FLOOR, SUITE 7
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3544
Practice Address - Country:US
Practice Address - Phone:310-802-3219
Practice Address - Fax:310-831-3000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A9264207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKH71564Medicare UPIN