Provider Demographics
NPI:1750461190
Name:THACKER, ANTHONY WAYNE (MD)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:WAYNE
Last Name:THACKER
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:ANTHONY
Other - Middle Name:WAYNE
Other - Last Name:THACKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1540 SPRING VALLEY DRIVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25704
Mailing Address - Country:US
Mailing Address - Phone:304-429-6741
Mailing Address - Fax:304-429-0262
Practice Address - Street 1:1540 SPRING VALLEY DRIVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25704
Practice Address - Country:US
Practice Address - Phone:304-429-6741
Practice Address - Fax:304-429-0262
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV17430207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001719401OtherBCBS
WV080173694OtherTRAVLERS MEDICARE
WV0053746000Medicaid
WV001719401OtherBCBS
WV0743955Medicare PIN