Provider Demographics
NPI:1134326275
Name:SOE, THAN (MD)
Entity Type:Individual
Prefix:DR
First Name:THAN
Middle Name:
Last Name:SOE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MR
Other - First Name:THAN
Other - Middle Name:S
Other - Last Name:FU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2415 W VINE ST STE 105
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-3731
Mailing Address - Country:US
Mailing Address - Phone:209-333-3121
Mailing Address - Fax:
Practice Address - Street 1:2415 W VINE ST STE 105
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-3731
Practice Address - Country:US
Practice Address - Phone:209-333-3121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA 100127207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine