Provider Demographics
NPI:1285659227
Name:THAI, PHONG AN (DPM)
Entity Type:Individual
Prefix:DR
First Name:PHONG
Middle Name:AN
Last Name:THAI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9301 218TH ST
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11428-1834
Mailing Address - Country:US
Mailing Address - Phone:718-740-3271
Mailing Address - Fax:718-740-3653
Practice Address - Street 1:9301 218TH ST
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11428-1834
Practice Address - Country:US
Practice Address - Phone:718-740-3271
Practice Address - Fax:718-740-3653
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005157213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01590394Medicaid
NY06702IMedicare PIN
U54716Medicare UPIN
P00241Medicare ID - Type Unspecified