Provider Demographics
NPI:1932191673
Name:THAKER, SUDEVI P (MD)
Entity Type:Individual
Prefix:DR
First Name:SUDEVI
Middle Name:P
Last Name:THAKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 E HARDING WAY
Mailing Address - Street 2:SUITE I
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-6118
Mailing Address - Country:US
Mailing Address - Phone:209-467-1001
Mailing Address - Fax:209-467-1005
Practice Address - Street 1:415 E HARDING WAY
Practice Address - Street 2:SUITE I
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-6118
Practice Address - Country:US
Practice Address - Phone:209-467-1001
Practice Address - Fax:209-467-1005
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC52147174400000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C521470Medicaid
CA00C521470Medicaid