Provider Demographics
NPI:1942260484
Name:THACKREY, DONNA T (MD)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:T
Last Name:THACKREY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DONNA
Other - Middle Name:T
Other - Last Name:PERDAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2740 S HIGHWAY 94
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63303-5609
Mailing Address - Country:US
Mailing Address - Phone:636-441-5437
Mailing Address - Fax:636-441-4398
Practice Address - Street 1:2740 S HIGHWAY 94
Practice Address - Street 2:SUITE A
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63303-5609
Practice Address - Country:US
Practice Address - Phone:636-441-5437
Practice Address - Fax:636-441-4398
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO106364208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
H26369Medicare UPIN