Provider Demographics
NPI:1982274098
Name:THAKUR, VISHAL VISHNU
Entity Type:Individual
Prefix:
First Name:VISHAL
Middle Name:VISHNU
Last Name:THAKUR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 9183
Mailing Address - Street 2:64 MEDICAL CENTRE DRIVE
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505
Mailing Address - Country:US
Mailing Address - Phone:304-293-5042
Mailing Address - Fax:304-293-4819
Practice Address - Street 1:33 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-4024
Practice Address - Country:US
Practice Address - Phone:304-293-5042
Practice Address - Fax:304-293-4819
Is Sole Proprietor?:No
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program