Provider Demographics
NPI:1649381302
Name:THAKUR, MRUDANGI (MD)
Entity Type:Individual
Prefix:DR
First Name:MRUDANGI
Middle Name:
Last Name:THAKUR
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 1:3650 HILL BLVD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10535-1500
Mailing Address - Country:US
Mailing Address - Phone:914-962-8888
Mailing Address - Fax:914-962-8881
Practice Address - Street 1:3650 HILL BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON VALLEY
Practice Address - State:NY
Practice Address - Zip Code:10535-1500
Practice Address - Country:US
Practice Address - Phone:914-962-8888
Practice Address - Fax:914-962-8881
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2020-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY210957208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02267889Medicaid
NYH 47125Medicare UPIN
NY513731Medicare ID - Type Unspecified