Provider Demographics
NPI:1275037145
Name:THACKER, BRIAN JAMES (DO)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:JAMES
Last Name:THACKER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3239
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29502-3239
Mailing Address - Country:US
Mailing Address - Phone:843-756-7885
Mailing Address - Fax:843-756-7855
Practice Address - Street 1:3418 CASEY ST
Practice Address - Street 2:
Practice Address - City:LORIS
Practice Address - State:SC
Practice Address - Zip Code:29569-2904
Practice Address - Country:US
Practice Address - Phone:843-756-7885
Practice Address - Fax:843-756-7855
Is Sole Proprietor?:No
Enumeration Date:2018-03-23
Last Update Date:2021-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC83714207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine