Provider Demographics
NPI:1568150662
Name:SANDEEP THAKKAR DO A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:SANDEEP THAKKAR DO A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOOKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-681-8693
Mailing Address - Street 1:16405 SAND CANYON AVE
Mailing Address - Street 2:SUITE 265
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-3792
Mailing Address - Country:US
Mailing Address - Phone:714-602-9891
Mailing Address - Fax:714-912-4181
Practice Address - Street 1:16405 SAND CANYON AVE
Practice Address - Street 2:SUITE 265
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3792
Practice Address - Country:US
Practice Address - Phone:714-602-9891
Practice Address - Fax:714-912-4181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-26
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty