Provider Demographics
NPI:1992742993
Name:THATAI, DEEPAK (MD)
Entity type:Individual
Prefix:
First Name:DEEPAK
Middle Name:
Last Name:THATAI
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 1:103 GARLAND ST
Mailing Address - Street 2:MEDICAL SPECIALTIES
Mailing Address - City:EVERETT
Mailing Address - State:MA
Mailing Address - Zip Code:02149-5066
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:103 GARLAND ST
Practice Address - Street 2:MEDICAL SPECIALTIES
Practice Address - City:EVERETT
Practice Address - State:MA
Practice Address - Zip Code:02149-5066
Practice Address - Country:US
Practice Address - Phone:617-843-0752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301069394207R00000X
MA238276207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2168235Medicaid
MA2168235Medicaid