Provider Demographics
NPI:1689683815
Name:THAKKAR, PRYIESH T (DO MBA)
Entity Type:Individual
Prefix:
First Name:PRYIESH
Middle Name:T
Last Name:THAKKAR
Suffix:
Gender:M
Credentials:DO MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:08225
Mailing Address - Country:US
Mailing Address - Phone:609-383-0200
Mailing Address - Fax:609-383-8352
Practice Address - Street 1:510 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:NJ
Practice Address - Zip Code:08225
Practice Address - Country:US
Practice Address - Phone:609-383-0200
Practice Address - Fax:609-383-8352
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB07722800207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0068951Medicaid
I10421Medicare UPIN
NJ0068951Medicaid