Provider Demographics
NPI:1558953661
Name:THAI, EMMY (OD)
Entity Type:Individual
Prefix:
First Name:EMMY
Middle Name:
Last Name:THAI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4855 CONDOR AVE
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-4715
Mailing Address - Country:US
Mailing Address - Phone:714-360-2858
Mailing Address - Fax:
Practice Address - Street 1:15268 SUMMIT AVE STE 300
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-0234
Practice Address - Country:US
Practice Address - Phone:909-279-2472
Practice Address - Fax:909-279-2479
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-09
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34754TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist