1790701712 NPI number — DR. RAJBALA THAKUR M.D.

Table of content: DR. RAJBALA THAKUR M.D. (NPI 1790701712)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790701712 NPI number — DR. RAJBALA THAKUR M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THAKUR
Provider First Name:
RAJBALA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790701712
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 ELMWOOD AVE
Provider Second Line Business Mailing Address:
BOX 604
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14642-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-275-5982
Provider Business Mailing Address Fax Number:
585-756-0169

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 ELMWOOD AVE
Provider Second Line Business Practice Location Address:
BOX 604
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14642-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-275-5982
Provider Business Practice Location Address Fax Number:
585-756-0169
Provider Enumeration Date:
07/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  199637 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LH0002X , with the licence number: 199637 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LP2900X , with the licence number: 199637 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7152065 . This is a "AETNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00040826601 . This is a "UNIVERA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00040826602 . This is a "UNIVERA PTC" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01576021 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: G0189393590 . This is a "BLUE CHOICE PTC GROUP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000912439001 . This is a "BS WNY/HEALTHNOW" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 5398992 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: G0189393590 . This is a "BLUE CHOICE GROUP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: MDG079 . This is a "PREFERRED CARE PTC" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 199637-0 . This is a "WORKER'S COMP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 2222 . This is a "BLUE SHIELD GROUP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 050059021 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 058157 . This is a "MVP PROVIDER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: MDA531 . This is a "PREFERRED CARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P010199637 . This is a "BLUE CHOICE PTC" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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