Provider Demographics
NPI:1558358135
Name:THAKER, YOGENDRA K (MD)
Entity Type:Individual
Prefix:
First Name:YOGENDRA
Middle Name:K
Last Name:THAKER
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 1:80 MECHANIC ST
Mailing Address - Street 2:
Mailing Address - City:ATHOL
Mailing Address - State:MA
Mailing Address - Zip Code:01331-3534
Mailing Address - Country:US
Mailing Address - Phone:978-249-2347
Mailing Address - Fax:978-249-6333
Practice Address - Street 1:80 MECHANIC ST
Practice Address - Street 2:
Practice Address - City:ATHOL
Practice Address - State:MA
Practice Address - Zip Code:01331-3534
Practice Address - Country:US
Practice Address - Phone:978-249-2347
Practice Address - Fax:978-249-6333
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-29
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA71439208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3050071439Medicaid
MA3050071439Medicaid
MAJ08458Medicare ID - Type Unspecified