Provider Demographics
NPI:1306167846
Name:THACKREY, JEFF (MD)
Entity type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:THACKREY
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 1:6400 N ANDREWS AVE
Mailing Address - Street 2:STE 120
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-2114
Mailing Address - Country:US
Mailing Address - Phone:954-688-4072
Mailing Address - Fax:954-653-7209
Practice Address - Street 1:6400 N ANDREWS AVE
Practice Address - Street 2:STE 120
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309-2114
Practice Address - Country:US
Practice Address - Phone:954-688-4072
Practice Address - Fax:954-653-7209
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-18
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME93287174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist