Provider Demographics
NPI:1558765941
Name:THAYER, KARISA (MD)
Entity Type:Individual
Prefix:DR
First Name:KARISA
Middle Name:
Last Name:THAYER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:742 W GARDENA BLVD
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-5024
Mailing Address - Country:US
Mailing Address - Phone:310-327-1357
Mailing Address - Fax:
Practice Address - Street 1:742 W GARDENA BLVD
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-5024
Practice Address - Country:US
Practice Address - Phone:310-327-1357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-14
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA140754208000000X, 207R00000X
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAKA3232267556).Medicaid