Provider Demographics
NPI:1568504173
Name:JASON W THACKERAY MD PA
Entity Type:Organization
Organization Name:JASON W THACKERAY MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:W
Authorized Official - Last Name:THACKERAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-863-2153
Mailing Address - Street 1:1034 MAR WALT DR STE 100
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6645
Mailing Address - Country:US
Mailing Address - Phone:850-863-2153
Mailing Address - Fax:850-315-9350
Practice Address - Street 1:1034 MAR WALT DR STE 100
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6645
Practice Address - Country:US
Practice Address - Phone:850-863-2153
Practice Address - Fax:850-315-9350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME77615207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL17147OtherBS PROVIDER NUMBER
FL265809700Medicaid
FL1568504173OtherRAILROAD MEDICARE
FLH70319Medicare UPIN
FL5232980001Medicare NSC
FLK3827Medicare PIN
FL17147OtherBS PROVIDER NUMBER
FL1568504173OtherRAILROAD MEDICARE
FL5232980003Medicare NSC