Provider Demographics
NPI:1568666352
Name:THAKRE, TUSHAR PURUSHOTTAM (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:TUSHAR
Middle Name:PURUSHOTTAM
Last Name:THAKRE
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 91734
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23291-1734
Mailing Address - Country:US
Mailing Address - Phone:804-358-6100
Mailing Address - Fax:804-342-7619
Practice Address - Street 1:2529 PROFESSIONAL RD
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235-3235
Practice Address - Country:US
Practice Address - Phone:804-323-2255
Practice Address - Fax:804-323-2362
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.0978052084P0800X, 2084S0012X
NC2012-010332084P0800X, 2084S0012X
VA01012548972084S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1568666352Medicaid
NC1708XOtherBCBSNC
NC5920340Medicaid
VAVVD843AMedicare PIN
DC354504ZBTPMedicare PIN
NCNC71650322Medicare PIN