Healthcare Provider Details

I. General information

NPI: 1689671851
Provider Name (Legal Business Name): MYO THANT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2005
Last Update Date: 07/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8605 51ST AVE
ELMHURST NY
11373-3921
US

IV. Provider business mailing address

4295 HAMPTON ST
ELMHURST NY
11373-3460
US

V. Phone/Fax

Practice location:
  • Phone: 718-361-6038
  • Fax: 718-760-0799
Mailing address:
  • Phone: 718-361-6038
  • Fax: 718-760-0799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number212485
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier02190178
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: