Provider Demographics
NPI:1184658635
Name:VO, THANH DAI (MD)
Entity Type:Individual
Prefix:DR
First Name:THANH
Middle Name:DAI
Last Name:VO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2520 BERT KOUNS
Mailing Address - Street 2:STE 102
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-3130
Mailing Address - Country:US
Mailing Address - Phone:318-212-5972
Mailing Address - Fax:318-212-5369
Practice Address - Street 1:2520 BERT KOUNS INDUSTRIAL LOOP
Practice Address - Street 2:SUITE 105
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3130
Practice Address - Country:US
Practice Address - Phone:318-212-5520
Practice Address - Fax:318-212-5540
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.200321207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4J956OtherMEDICARE PTAN
LA1056502Medicaid
LA5C537Medicare ID - Type Unspecified
LAI45230Medicare UPIN