Provider Demographics
NPI:1649291568
Name:THAKARAR, PUSHPA T (MD)
Entity type:Individual
Prefix:
First Name:PUSHPA
Middle Name:T
Last Name:THAKARAR
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 1:902 MADISON DR
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-3101
Mailing Address - Country:US
Mailing Address - Phone:610-647-0591
Mailing Address - Fax:610-647-2448
Practice Address - Street 1:902 MADISON DR
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:PA
Practice Address - Zip Code:19355-3101
Practice Address - Country:US
Practice Address - Phone:610-647-0591
Practice Address - Fax:610-647-2448
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-018899-E2081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA06516660004Medicaid
PA06516660004Medicaid
B35108Medicare UPIN