Provider Demographics
NPI:1730238270
Name:THAI, AN NGOC (MD)
Entity type:Individual
Prefix:DR
First Name:AN
Middle Name:NGOC
Last Name:THAI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:AN
Other - Middle Name:N
Other - Last Name:THAI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:16 GLEASON ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-1608
Mailing Address - Country:US
Mailing Address - Phone:617-926-2193
Mailing Address - Fax:617-265-0086
Practice Address - Street 1:1443B DORCHESTER AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122-1347
Practice Address - Country:US
Practice Address - Phone:617-265-0955
Practice Address - Fax:617-265-0086
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA50544207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6181287Medicaid
MA6181287Medicaid
MAEO5987Medicare ID - Type UnspecifiedFEDERAL