Provider Demographics
NPI:1053413682
Name:THAVER, NIMSHAVATHANI (DO)
Entity type:Individual
Prefix:DR
First Name:NIMSHAVATHANI
Middle Name:
Last Name:THAVER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1260 E WOODLAND AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SPRINGFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:19064-3969
Mailing Address - Country:US
Mailing Address - Phone:610-690-4490
Mailing Address - Fax:610-328-9391
Practice Address - Street 1:1260 E WOODLAND AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SPRINGFIELD
Practice Address - State:PA
Practice Address - Zip Code:19064-3969
Practice Address - Country:US
Practice Address - Phone:610-690-4490
Practice Address - Fax:610-328-9391
Is Sole Proprietor?:No
Enumeration Date:2006-09-03
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS015380207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1026440190001Medicaid
PA224612Medicare PIN