1962247973 NPI number — MIIMII THAE DPM, P.A

Table of content: (NPI 1962247973)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962247973 NPI number — MIIMII THAE DPM, P.A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIIMII THAE DPM, P.A
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962247973
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/30/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4236 SW 124TH TER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIRAMAR
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33027-6009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-496-0596
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
381 N KROME AVE STE 112
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOMESTEAD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33030-6047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-246-4774
Provider Business Practice Location Address Fax Number:
305-248-4086
Provider Enumeration Date:
07/01/2024

Additional Information

Authorized Official

Authorized Official Last Name:
THAE
Authorized Official First Name:
MIIMII
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT /OWNER
Authorized Official Telephone Number:
305-496-0596

Provider Taxonomy Codes

  • Taxonomy code: 261QP1100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PO4559 . This is a "PODIATRIC PHYSICIAN LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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