Provider Demographics
NPI:1760749246
Name:MAI, SOPHIA (MD)
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:
Last Name:MAI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1051 GAUSE BLVD
Mailing Address - Street 2:#460
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-2951
Mailing Address - Country:US
Mailing Address - Phone:985-649-5880
Mailing Address - Fax:
Practice Address - Street 1:1051 GAUSE BLVD
Practice Address - Street 2:#460
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-2951
Practice Address - Country:US
Practice Address - Phone:985-649-5880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-20
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA390200000X
LA301735207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program