Provider Demographics
NPI:1720090871
Name:THAKKAR, DHAVAL N (MD)
Entity Type:Individual
Prefix:
First Name:DHAVAL
Middle Name:N
Last Name:THAKKAR
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 1:1850 GATEWAY DR
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3192
Mailing Address - Country:US
Mailing Address - Phone:815-758-8671
Mailing Address - Fax:
Practice Address - Street 1:1850 GATEWAY DR
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3192
Practice Address - Country:US
Practice Address - Phone:815-758-8671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-103399207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036103399Medicaid
IL062767OtherHEALTH ALLIANCE
IL036103399Medicaid
IL612990Medicare PIN