Provider Demographics
NPI:1104920297
Name:THAO, MAIYA DRUE (DPM)
Entity type:Individual
Prefix:
First Name:MAIYA
Middle Name:DRUE
Last Name:THAO
Suffix:
Gender:F
Credentials:DPM
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 3768
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95344-3768
Mailing Address - Country:US
Mailing Address - Phone:209-384-3198
Mailing Address - Fax:209-725-1603
Practice Address - Street 1:378 W OLIVE AVE
Practice Address - Street 2:SUITE C
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95348-3137
Practice Address - Country:US
Practice Address - Phone:209-384-3198
Practice Address - Fax:209-725-1603
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4489213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E44890Medicaid
CAU96636Medicare UPIN
CA000E44890Medicare PIN