Provider Demographics
NPI:1023258415
Name:MAI, CONG THANH (DPM)
Entity type:Individual
Prefix:
First Name:CONG
Middle Name:THANH
Last Name:MAI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:12062 VALLEY VIEW ST STE 131
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92845-1741
Mailing Address - Country:US
Mailing Address - Phone:714-465-2178
Mailing Address - Fax:714-465-2179
Practice Address - Street 1:12062 VALLEY VIEW ST STE 131
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92845-1741
Practice Address - Country:US
Practice Address - Phone:714-465-2178
Practice Address - Fax:714-465-2179
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-25
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4793213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA172298Medicare PIN