Provider Demographics
NPI:1588876833
Name:THAKUR, SIVAREVATHI (MD)
Entity type:Individual
Prefix:DR
First Name:SIVAREVATHI
Middle Name:
Last Name:THAKUR
Suffix:
Gender:F
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:P.O. BOX 660599
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75266-0599
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3320 LIVE OAK STREET
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-6109
Practice Address - Country:US
Practice Address - Phone:214-266-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN5431207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX283104201Medicaid
TX283104202Medicaid
TX283104205Medicaid
TX8CU881OtherBCBS
TX283104208Medicaid
TX283104204Medicaid
TX283104207Medicaid
TX283104203Medicaid
TX283104209Medicaid
TX283104201Medicaid