Provider Demographics
NPI:1588703409
Name:TANLAMAI, THEANCHAI - (OD)
Entity type:Individual
Prefix:DR
First Name:THEANCHAI
Middle Name:-
Last Name:TANLAMAI
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 1:215 NEWBURY ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-2518
Mailing Address - Country:US
Mailing Address - Phone:617-437-1364
Mailing Address - Fax:617-424-8070
Practice Address - Street 1:215 NEWBURY ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-2518
Practice Address - Country:US
Practice Address - Phone:617-437-1364
Practice Address - Fax:617-424-8070
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA3258152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPN 0334481Medicaid
MATA A32489Medicare ID - Type Unspecified