Provider Demographics
NPI:1285785915
Name:THAANUM, MICHAEL JAMES (OD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:THAANUM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 DEL MONTE SHOPPIING CENTER
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940
Mailing Address - Country:US
Mailing Address - Phone:831-375-3771
Mailing Address - Fax:831-375-1524
Practice Address - Street 1:500 SOUTHLAND MALL
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94545-2148
Practice Address - Country:US
Practice Address - Phone:510-887-2800
Practice Address - Fax:510-887-2812
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6571TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1306035118Medicaid
CA1306035118OtherRETIRED RAILROAD MEDICARE
CA6191070001OtherDME MACS PTAN
CA6191070001OtherDME MACS PTAN
CA1306035118Medicaid
CADP2509Medicare PIN
CA1306035118OtherRETIRED RAILROAD MEDICARE
CASDO065710Medicare ID - Type Unspecified
CAPTAN BR184Medicare PIN