Individual
CLIFFORD LEE THACKER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
12550 NEW BRITTANY BLVD STE 201, FORT MYERS, FL 33907
(239) 343-9190
(239) 343-9193
Mailing address
PO BOX 2147, FORT MYERS, FL 33902-2147
(239) 343-9190
(239) 343-9193
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
ME70754
FL
207QA0401X
Addiction Medicine (Family Medicine) Physician
Primary
ME70754
FL
207V00000X
Obstetrics & Gynecology Physician
ME0070754
FL
2084P0800X
Psychiatry Physician
ME70754
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
101588900
—
FL
Enumeration date
09/21/2005
Last updated
07/21/2022
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