Provider Demographics
NPI:1952369191
Name:THAKER, KUNTAL M (MD)
Entity Type:Individual
Prefix:DR
First Name:KUNTAL
Middle Name:M
Last Name:THAKER
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 1:2025 SOQUEL AVE.
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-1323
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2850 COMMERCIAL CROSSING
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065-1702
Practice Address - Country:US
Practice Address - Phone:831-460-7350
Practice Address - Fax:831-460-7351
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-4883207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR161442001Medicaid
AR5N551Medicare ID - Type Unspecified
ARH75927Medicare UPIN