Provider Demographics
NPI:1861021255
Name:DO, TAI (MD)
Entity type:Individual
Prefix:DR
First Name:TAI
Middle Name:
Last Name:DO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 TRACE RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30157-9578
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:677 CHURCH STREET
Practice Address - Street 2:ATTN: GME
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060
Practice Address - Country:US
Practice Address - Phone:770-793-5186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-07
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA96086207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine