Provider Demographics
NPI:1316448814
Name:MARTA V THAKKAR, MD,SC
Entity type:Organization
Organization Name:MARTA V THAKKAR, MD,SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTA
Authorized Official - Middle Name:V
Authorized Official - Last Name:THAKKAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-447-2674
Mailing Address - Street 1:1050 W KESWICK LN
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1138
Mailing Address - Country:US
Mailing Address - Phone:847-505-6150
Mailing Address - Fax:
Practice Address - Street 1:3070 N 51ST ST
Practice Address - Street 2:P309
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-1645
Practice Address - Country:US
Practice Address - Phone:414-447-2764
Practice Address - Fax:414-447-2884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-21
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI479422080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Single Specialty