Provider Demographics
NPI:1003954033
Name:TA, XUANMAI THI (OD)
Entity Type:Individual
Prefix:DR
First Name:XUANMAI
Middle Name:THI
Last Name:TA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12167 CARTWAY CURV
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55347-4254
Mailing Address - Country:US
Mailing Address - Phone:612-871-1518
Mailing Address - Fax:612-871-2525
Practice Address - Street 1:2718 NICOLLET AVE
Practice Address - Street 2:SUITE NO. 103
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-1648
Practice Address - Country:US
Practice Address - Phone:612-871-1518
Practice Address - Fax:612-871-2585
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNT2107152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNT97995Medicare UPIN