Provider Demographics
NPI:1679611461
Name:THACKER, VASANT MUKUND (MD)
Entity Type:Individual
Prefix:
First Name:VASANT
Middle Name:MUKUND
Last Name:THACKER
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 1:3 PINEHURST ROAD
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MA
Mailing Address - Zip Code:02478-1517
Mailing Address - Country:US
Mailing Address - Phone:617-484-3668
Mailing Address - Fax:781-391-9929
Practice Address - Street 1:101 MAIN ST
Practice Address - Street 2:#210
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-4530
Practice Address - Country:US
Practice Address - Phone:781-396-8100
Practice Address - Fax:781-391-9929
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA39145207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0129917Medicaid
MA0129917Medicaid
B07186Medicare ID - Type Unspecified