Provider Demographics
NPI:1366508541
Name:MAI, THACH D (DO)
Entity Type:Individual
Prefix:DR
First Name:THACH
Middle Name:D
Last Name:MAI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3617
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91944-3617
Mailing Address - Country:US
Mailing Address - Phone:619-460-5111
Mailing Address - Fax:619-460-7815
Practice Address - Street 1:5555 GROSSMONT CENTER DR
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3019
Practice Address - Country:US
Practice Address - Phone:619-460-5111
Practice Address - Fax:619-460-7815
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207A7093207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA70930Medicare UPIN
CA20A7093AMedicare ID - Type Unspecified