Provider Demographics
NPI:1962247973
Name:MIIMII THAE DPM, P.A
Entity type:Organization
Organization Name:MIIMII THAE DPM, P.A
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT /OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MIIMII
Authorized Official - Middle Name:
Authorized Official - Last Name:THAE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:305-496-0596
Mailing Address - Street 1:4236 SW 124TH TER
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-6009
Mailing Address - Country:US
Mailing Address - Phone:305-496-0596
Mailing Address - Fax:
Practice Address - Street 1:381 N KROME AVE STE 112
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-6047
Practice Address - Country:US
Practice Address - Phone:305-246-4774
Practice Address - Fax:305-248-4086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-01
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPO4559OtherPODIATRIC PHYSICIAN LICENSE