Provider Demographics
NPI:1396876058
Name:THAN, LINH TRANG THAI (OD)
Entity type:Individual
Prefix:DR
First Name:LINH TRANG
Middle Name:THAI
Last Name:THAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:AGNES LINH TRANG
Other - Middle Name:THAI
Other - Last Name:THAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:4520 OLDE PERIMETER WAY STE 110
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30346-4210
Mailing Address - Country:US
Mailing Address - Phone:770-500-3937
Mailing Address - Fax:770-500-3552
Practice Address - Street 1:4520 OLDE PERIMETER WAY STE 110
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30346-4210
Practice Address - Country:US
Practice Address - Phone:770-500-3937
Practice Address - Fax:770-500-3552
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOP001575152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU96164Medicare UPIN