Provider Demographics
NPI:1063403061
Name:THACH, THAO (MD)
Entity type:Individual
Prefix:
First Name:THAO
Middle Name:
Last Name:THACH
Suffix:
Gender:F
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:PO BOX 453187
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75045-3187
Mailing Address - Country:US
Mailing Address - Phone:214-703-9700
Mailing Address - Fax:214-703-9811
Practice Address - Street 1:325 N SHILOH RD
Practice Address - Street 2:STE. 103
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75042-6610
Practice Address - Country:US
Practice Address - Phone:214-703-9700
Practice Address - Fax:214-703-9811
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6667207WX0009X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX165716504Medicaid
TX611298Medicare PIN
CAH584888Medicare UPIN
TX8F0593Medicare PIN
TX5453290001Medicare NSC