Provider Demographics
NPI:1184633430
Name:NICOLE HONG PHUONG T. THAI , M.D., INC
Entity Type:Organization
Organization Name:NICOLE HONG PHUONG T. THAI , M.D., INC
Other - Org Name:NICOLE THAI M.D., INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:HONG PHUONG
Authorized Official - Last Name:THAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-928-5656
Mailing Address - Street 1:200 JOSE FIGUERES AVE
Mailing Address - Street 2:SUITE 355
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95116
Mailing Address - Country:US
Mailing Address - Phone:408-928-5656
Mailing Address - Fax:408-928-5626
Practice Address - Street 1:200 JOSE FIGUERES AVE
Practice Address - Street 2:SUITE 355
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116
Practice Address - Country:US
Practice Address - Phone:408-928-5656
Practice Address - Fax:408-928-5626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA47898207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ02542ZMedicare PIN