Basic Information
| Provider Information | |||||||||
| NPI: | 1346357092 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THAKARE | ||||||||
| FirstName: | PRADEEP | ||||||||
| MiddleName: | V | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23998 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392253998 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6627252749 | ||||||||
| FaxNumber: | 6627252741 | ||||||||
| Practice Location | |||||||||
| Address1: | 1502 S COLORADO ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 387037219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623329872 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 09/26/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 08305 | MS | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | P00258364 | 01 | RR MEDICARE | OTHER | 01636822 | 05 | MS | MEDICAID | 1527882 | 05 | LA | MEDICAID |