Healthcare Provider Details

I. General information

NPI: 1972204667
Provider Name (Legal Business Name): VINCENT THIEU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2023
Last Update Date: 08/02/2024
Certification Date: 08/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3134 N CLARK ST
CHICAGO IL
60657-4414
US

IV. Provider business mailing address

3134 N CLARK ST
CHICAGO IL
60657-4414
US

V. Phone/Fax

Practice location:
  • Phone: 312-766-4949
  • Fax:
Mailing address:
  • Phone: 248-250-3759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125.084134
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: