Provider Demographics
NPI:1508814195
Name:U, THA T (MD)
Entity Type:Individual
Prefix:DR
First Name:THA
Middle Name:T
Last Name:U
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2800 GODWIN BLVD
Mailing Address - Street 2:STE. 320
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-8038
Mailing Address - Country:US
Mailing Address - Phone:757-934-4580
Mailing Address - Fax:757-934-4581
Practice Address - Street 1:2800 GODWIN BLVD
Practice Address - Street 2:STE. 320
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-8038
Practice Address - Country:US
Practice Address - Phone:757-934-4580
Practice Address - Fax:757-934-4581
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012348532084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP00205034OtherRAILROAD MEDICARE
VA465662OtherANTHEM
VA0100006279Medicaid
VAGC1000Medicare PIN
VA190000823Medicare PIN
VA0100006279Medicaid