Provider Demographics
NPI:1750323010
Name:THAKUR, SHIVENDER K
Entity Type:Individual
Prefix:
First Name:SHIVENDER
Middle Name:K
Last Name:THAKUR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:890 WESTFALL RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-2610
Mailing Address - Country:US
Mailing Address - Phone:585-442-6960
Mailing Address - Fax:585-442-3548
Practice Address - Street 1:890 WESTFALL RD
Practice Address - Street 2:SUITE B
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-2610
Practice Address - Country:US
Practice Address - Phone:585-442-6960
Practice Address - Fax:585-442-3548
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY192844207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00027284401OtherUNIVERA #
NY050906000002OtherFIDELIS CARE #
NY192844-9WOtherWORKERS COMP #
NY0491669OtherIHA #
NYP010192844OtherBLUE CHOICE #
NY101474BJOtherPREFERRED CARE #
NYP010192844OtherBLUE CHOICE #