Provider Demographics
NPI:1659792802
Name:THAKAR, OPAL (MD)
Entity Type:Individual
Prefix:
First Name:OPAL
Middle Name:
Last Name:THAKAR
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 1:552 WESTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BRANCH
Mailing Address - State:NJ
Mailing Address - Zip Code:07740-5239
Mailing Address - Country:US
Mailing Address - Phone:732-222-7800
Mailing Address - Fax:732-571-2075
Practice Address - Street 1:552 WESTWOOD AVE
Practice Address - Street 2:
Practice Address - City:LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07740-5239
Practice Address - Country:US
Practice Address - Phone:732-222-7800
Practice Address - Fax:732-571-2075
Is Sole Proprietor?:No
Enumeration Date:2013-12-13
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09804000207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0534196Medicaid
NJ537652WNCMedicare PIN