Provider Demographics
NPI:1679502538
Name:THACKER, BRETT MCKINNEY (MD)
Entity Type:Individual
Prefix:DR
First Name:BRETT
Middle Name:MCKINNEY
Last Name:THACKER
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 1:201 FERRIS AVE STE I
Mailing Address - Street 2:
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165-3660
Mailing Address - Country:US
Mailing Address - Phone:972-937-1613
Mailing Address - Fax:972-923-7190
Practice Address - Street 1:201 FERRIS AVENUE
Practice Address - Street 2:SUITE I
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165
Practice Address - Country:US
Practice Address - Phone:972-937-1613
Practice Address - Fax:972-923-7190
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-02
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG0195207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX114635902Medicaid
B26932Medicare UPIN
TX114635902Medicaid