Basic Information
| Provider Information | |||||||||
| NPI: | 1699816074 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THAKUR | ||||||||
| FirstName: | SANJAY | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 308 | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | WARTBURG | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378870308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233465566 | ||||||||
| FaxNumber: | 4233465631 | ||||||||
| Practice Location | |||||||||
| Address1: | 1236 KNOXVILLE HWY | ||||||||
| Address2: | |||||||||
| City: | WARTBURG | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37887 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233465566 | ||||||||
| FaxNumber: | 4233465631 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2007 | ||||||||
| LastUpdateDate: | 02/08/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD0000034058 | TN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3156190 | 01 | TN | BCBS | OTHER | 103I08324 | 01 | TN | MEDICARE | OTHER | 3853052 | 05 | TN | MEDICAID | BT6727830 | 01 | TN | DEA | OTHER |