Provider Demographics
NPI:1134797905
Name:THAE, MIIMII (DPM)
Entity type:Individual
Prefix:DR
First Name:MIIMII
Middle Name:
Last Name:THAE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:MIIMII
Other - Middle Name:
Other - Last Name:THAE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM, PA
Mailing Address - Street 1:4236 SW 124TH TER
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-6009
Mailing Address - Country:US
Mailing Address - Phone:305-496-0596
Mailing Address - Fax:
Practice Address - Street 1:381 N KROME AVE STE 112
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-6047
Practice Address - Country:US
Practice Address - Phone:305-246-4774
Practice Address - Fax:305-248-4086
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-16
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLPO4559213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program