Provider Demographics
NPI:1821424441
Name:THAO, DAVID (IDMT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:THAO
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1231 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-6546
Mailing Address - Country:US
Mailing Address - Phone:830-765-2627
Mailing Address - Fax:
Practice Address - Street 1:1231 MONROE ST
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-6546
Practice Address - Country:US
Practice Address - Phone:830-765-2627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-16
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians