Provider Demographics
NPI:1942282926
Name:TA, MINDY THANH MINH (OD)
Entity Type:Individual
Prefix:DR
First Name:MINDY
Middle Name:THANH MINH
Last Name:TA
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:PO BOX 22009
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97269-2009
Mailing Address - Country:US
Mailing Address - Phone:503-558-7372
Mailing Address - Fax:503-344-5140
Practice Address - Street 1:11086 SE OAK ST
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-6692
Practice Address - Country:US
Practice Address - Phone:503-656-4221
Practice Address - Fax:503-656-4249
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2021-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3140T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR213509Medicaid
V06247Medicare UPIN
OR132383Medicare PIN