Provider Demographics
NPI:1326135021
Name:PHAN, THAI (MD)
Entity Type:Individual
Prefix:DR
First Name:THAI
Middle Name:
Last Name:PHAN
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 1:1321 ASHLEYBROOK LN
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-2918
Mailing Address - Country:US
Mailing Address - Phone:336-659-9440
Mailing Address - Fax:336-659-9845
Practice Address - Street 1:1321 ASHLEYBROOK LN
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2918
Practice Address - Country:US
Practice Address - Phone:336-659-9440
Practice Address - Fax:336-659-9845
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28930174400000X, 2084P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC67433OtherBCBS
NC8967433Medicaid
NCC23975Medicare UPIN
NC67433OtherBCBS