Basic Information
| Provider Information | |||||||||
| NPI: | 1396731857 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THACKER | ||||||||
| FirstName: | CLIFFORD | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2147 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339022147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393439190 | ||||||||
| FaxNumber: | 2393439193 | ||||||||
| Practice Location | |||||||||
| Address1: | 12550 NEW BRITTANY BLVD STE 201 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393439190 | ||||||||
| FaxNumber: | 2393439193 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME70754 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207V00000X | ME0070754 | FL | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 2084P0800X | ME70754 | FL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 207QA0401X | ME70754 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine |
ID Information
| ID | Type | State | Issuer | Description | 101588900 | 05 | FL | MEDICAID |