Provider Demographics
NPI:1437151453
Name:THACKERAY, JONATHAN DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:DAVID
Last Name:THACKERAY
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:PO BOX 933432
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0039
Mailing Address - Country:US
Mailing Address - Phone:937-641-3000
Mailing Address - Fax:
Practice Address - Street 1:1 CHILDRENS PLZ
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45404-1815
Practice Address - Country:US
Practice Address - Phone:937-641-4000
Practice Address - Fax:937-641-3918
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.083628208000000X, 2080C0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080C0008XAllopathic & Osteopathic PhysiciansPediatricsChild Abuse Pediatrics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2545026Medicaid
KY2545026Medicaid
OH2545026Medicaid
KY2545026Medicaid
OHTH4161911Medicare ID - Type Unspecified