Provider Demographics
NPI:1871541961
Name:THAKER, NIMISH (MD)
Entity type:Individual
Prefix:
First Name:NIMISH
Middle Name:
Last Name:THAKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1791 E HOLT BLVD UNIT 101
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-2118
Mailing Address - Country:US
Mailing Address - Phone:909-460-0354
Mailing Address - Fax:909-460-0367
Practice Address - Street 1:1791 E HOLT BLVD UNIT 101
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-2118
Practice Address - Country:US
Practice Address - Phone:909-460-0354
Practice Address - Fax:909-460-0367
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA747570174400000X
CAA74757208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A747570Medicare ID - Type Unspecified