Basic Information
| Provider Information | |||||||||
| NPI: | 1528552411 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAI | ||||||||
| FirstName: | THANH-VAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 99 HAWLEY LANE, FL. 3, CB-3427 | ||||||||
| Address2: | NORTHEAST MEDICAL GROUP, INC. | ||||||||
| City: | STRATFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066141202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035024650 | ||||||||
| FaxNumber: | 4752469894 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 SANDY DESERT RD | ||||||||
| Address2: | |||||||||
| City: | UNCASVILLE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063821112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604643800 | ||||||||
| FaxNumber: | 8604643601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2018 | ||||||||
| LastUpdateDate: | 09/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 69531 | CT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1528552411 | 05 | CT | MEDICAID |