Healthcare Provider Details

I. General information

NPI: 1447319629
Provider Name (Legal Business Name): THANH-LOAN DORSAM OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 CONNECTICUT AVE NW
WASHINGTON DC
20036-1801
US

IV. Provider business mailing address

1950 OLD GALLOWS RD STE 100
VIENNA VA
22182-3990
US

V. Phone/Fax

Practice location:
  • Phone: 202-785-5700
  • Fax: 202-223-6315
Mailing address:
  • Phone: 703-847-8899
  • Fax: 703-847-5177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number502MM869
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOP1000098
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTA9147
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: