Provider Demographics
NPI:1528031747
Name:THACKER, TODD ALAN (DO)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:ALAN
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 1:1705 E 11TH ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78702-2709
Mailing Address - Country:US
Mailing Address - Phone:512-978-8400
Mailing Address - Fax:
Practice Address - Street 1:1705 E 11TH ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78702-2709
Practice Address - Country:US
Practice Address - Phone:512-978-8400
Practice Address - Fax:512-901-9785
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDOS-1710207Q00000X
TXJ9383207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF43342Medicare UPIN
TX8617M3Medicare ID - Type Unspecified