Provider Demographics
NPI:1255434353
Name:THAKUR, ANITA (MD)
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:
Last Name:THAKUR
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 1:13706 N MARTIN WAY
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53097
Mailing Address - Country:US
Mailing Address - Phone:262-243-9880
Mailing Address - Fax:
Practice Address - Street 1:2323 N LAKE DRIVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211
Practice Address - Country:US
Practice Address - Phone:414-291-1989
Practice Address - Fax:414-291-1129
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI43392207ZC0500X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Not Answered207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34254000Medicaid
G20892Medicare UPIN