Provider Demographics
NPI:1578502167
Name:THAKUR, GAUTAM C (MD)
Entity Type:Individual
Prefix:
First Name:GAUTAM
Middle Name:C
Last Name:THAKUR
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:PO BOX 1420
Mailing Address - Street 2:
Mailing Address - City:CLEARFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:16830-5420
Mailing Address - Country:US
Mailing Address - Phone:877-235-7686
Mailing Address - Fax:814-235-1566
Practice Address - Street 1:751 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-2559
Practice Address - Country:US
Practice Address - Phone:814-333-5144
Practice Address - Fax:814-373-2255
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD061648L2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016368510004Medicaid
PA0016368510004Medicaid
G43935Medicare UPIN