Provider Demographics
NPI:1396731857
Name:THACKER, CLIFFORD LEE (MD)
Entity type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:LEE
Last Name:THACKER
Suffix:
Gender:M
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-9190
Mailing Address - Fax:239-343-9193
Practice Address - Street 1:12550 NEW BRITTANY BLVD STE 201
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907
Practice Address - Country:US
Practice Address - Phone:239-343-9190
Practice Address - Fax:239-343-9193
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME70754207Q00000X, 2084P0800X, 207QA0401X
FLME0070754207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101588900Medicaid
FL31505ZMedicare ID - Type Unspecified