Provider Demographics
NPI:1831355569
Name:THAKUR, SHANTANU KUMAR (MD)
Entity type:Individual
Prefix:
First Name:SHANTANU
Middle Name:KUMAR
Last Name:THAKUR
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 1:440 N BARRANCA AVE STE 9202
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-1722
Mailing Address - Country:US
Mailing Address - Phone:213-283-9202
Mailing Address - Fax:213-260-2306
Practice Address - Street 1:13039 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-2925
Practice Address - Country:US
Practice Address - Phone:213-283-9202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-01
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA119550208100000X, 2081H0002X, 2081P2900X, 2081P0301X
AZ462362081P0301X
OH35.1300142081P0301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P0301XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationBrain Injury Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081H0002XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationHospice and Palliative Medicine
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine