Healthcare Provider Details

I. General information

NPI: 1962247973
Provider Name (Legal Business Name): MIIMII THAE DPM, P.A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2024
Last Update Date: 08/30/2024
Certification Date: 08/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

381 N KROME AVE STE 112
HOMESTEAD FL
33030-6047
US

IV. Provider business mailing address

4236 SW 124TH TER
MIRAMAR FL
33027-6009
US

V. Phone/Fax

Practice location:
  • Phone: 305-246-4774
  • Fax: 305-248-4086
Mailing address:
  • Phone: 305-496-0596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MIIMII THAE
Title or Position: PRESIDENT /OWNER
Credential: DPM
Phone: 305-496-0596