Basic Information
| Provider Information | |||||||||
| NPI: | 1003854274 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THACKER | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | W. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 51238 | ||||||||
| Address2: | ATTENTION: MAGGIE NOLES | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900515538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5627414461 | ||||||||
| FaxNumber: | 5627414413 | ||||||||
| Practice Location | |||||||||
| Address1: | 340 W CENTRAL AVE STE 110 | ||||||||
| Address2: | ATTENTION: MAGGIE NOLES | ||||||||
| City: | BREA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928213006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145293971 | ||||||||
| FaxNumber: | 7145291070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 07/16/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20A5071 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00AX50710 | 05 | CA | MEDICAID |