Jason W Thackeray MD PA

Primary specialty

Sports Medicine (Orthopaedic Surgery) PhysicianTaxonomy code 207XX0005X

License

ME77615 Issued in FL

Legal business name

JASON W THACKERAY MD PA

Practice address

1034 Mar Walt Dr Ste 100
Fort Walton Beach, FL 32547-6645

Phone

(850) 863-2153

Fax

(850) 315-9350

NPI assigned

Feb 12, 2007

Last updated

Oct 29, 2020By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Jason W Thackeray, M.D.NPI 1235133646

Title

Physician

Phone

(850) 863-2153

Specialties & licenses 1

Addresses

Other identifiers 3

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Jason W Thackeray, M.D.

  • Orthopaedic Surgery Physician
  • Fort Walton Beach, FL
  • NPI 1235133646
  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1171238400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1603929600000",
    "number": "1568504173",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1034 MAR WALT DR STE 100",
            "city": "FORT WALTON BEACH",
            "state": "FL",
            "postal_code": "325476645",
            "telephone_number": "850-863-2153",
            "fax_number": "850-315-9350"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1034 MAR WALT DR STE 100",
            "city": "FORT WALTON BEACH",
            "state": "FL",
            "postal_code": "325476645",
            "telephone_number": "850-863-2153",
            "fax_number": "850-315-9350"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "JASON W THACKERAY MD PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-02-12",
        "last_updated": "2020-10-29",
        "certification_date": "2020-10-29",
        "status": "A",
        "authorized_official_last_name": "THACKERAY",
        "authorized_official_first_name": "JASON",
        "authorized_official_middle_name": "W",
        "authorized_official_title_or_position": "PHYSICIAN",
        "authorized_official_telephone_number": "850-863-2153",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "207XX0005X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Orthopaedic Surgery, Sports Medicine",
            "state": "FL",
            "license": "ME77615",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BS PROVIDER NUMBER",
            "identifier": "17147",
            "state": "FL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "265809700",
            "state": "FL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "1568504173",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Sports Medicine (Orthopaedic Surgery) Physician in Fort Walton Beach, FL
• Providers in Fort Walton Beach, FL by specialty
• Sports Medicine (Orthopaedic Surgery) Physician in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 29, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.