Healthcare Provider Details

I. General information

NPI: 1902595523
Provider Name (Legal Business Name): MENTOR THAQI DPM/PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2023
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 RIVERSIDE CIR
ROANOKE VA
24016-4955
US

IV. Provider business mailing address

213 S JEFFERSON ST STE 1006
ROANOKE VA
24011-1713
US

V. Phone/Fax

Practice location:
  • Phone: 540-510-6200
  • Fax: 540-857-5306
Mailing address:
  • Phone: 540-224-5516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number0103301508
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: