Provider Demographics
NPI:1457928558
Name:THAI, AMANDA (OD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:THAI
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 1:4240 KEARNY MESA RD STE 101
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-3769
Mailing Address - Country:US
Mailing Address - Phone:858-565-1001
Mailing Address - Fax:858-565-1004
Practice Address - Street 1:4240 KEARNY MESA RD STE 101
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-3769
Practice Address - Country:US
Practice Address - Phone:858-565-1001
Practice Address - Fax:858-565-1004
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-07
Last Update Date:2025-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34861152W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program