Provider Demographics
NPI:1194704767
Name:THACKER, DAVE H (MD)
Entity type:Individual
Prefix:DR
First Name:DAVE
Middle Name:H
Last Name:THACKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:5144 VILLAGE WOOD CT
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84120-4585
Mailing Address - Country:US
Mailing Address - Phone:801-982-1528
Mailing Address - Fax:
Practice Address - Street 1:7321 11TH ST
Practice Address - Street 2:75 MDG/SGOPC
Practice Address - City:HILL AFB
Practice Address - State:UT
Practice Address - Zip Code:84056-5012
Practice Address - Country:US
Practice Address - Phone:801-777-6804
Practice Address - Fax:801-586-4018
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT340105-1205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics