Healthcare Provider Details

I. General information

NPI: 1750329892
Provider Name (Legal Business Name): KIET VI THAI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 03/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

643 WASHINGTON AVE
PHILADELPHIA PA
19147-4825
US

IV. Provider business mailing address

695 SPROUL RD
BRYN MAWR PA
19010-1112
US

V. Phone/Fax

Practice location:
  • Phone: 215-462-1290
  • Fax: 215-462-1105
Mailing address:
  • Phone: 610-716-1750
  • Fax: 215-462-1110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD040810-L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: