Provider Demographics
NPI:1891761524
Name:TRAN, THAO NGUYEN (MD)
Entity Type:Individual
Prefix:
First Name:THAO
Middle Name:NGUYEN
Last Name:TRAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:THAO
Other - Middle Name:KIMPHUONG
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:7201 GREEN BAY RD STE C
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-3532
Mailing Address - Country:US
Mailing Address - Phone:262-842-2358
Mailing Address - Fax:888-959-8367
Practice Address - Street 1:7201 GREEN BAY RD STE C
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-3532
Practice Address - Country:US
Practice Address - Phone:262-842-2358
Practice Address - Fax:888-959-8367
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44790-20207W00000X
IL036099127207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400133004OtherMEDICARE PTAN
WI44790-20OtherWISCONSIN LICENSE
IL036099127OtherILLINOIS LICENSE
11357585OtherCAQH
ILF400110685OtherMEDICARE PTAN
WI34243100Medicaid
ILBT6306484OtherDEA
WI34243100Medicaid
WIK400133004OtherMEDICARE PTAN
WIFT4495885OtherDEA