=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598922825
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAM THANH MAI M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2008
-----------------------------------------------------
Last Update Date | 04/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3530 KRAFT RD STE 202
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34105-5020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-758-7465
-----------------------------------------------------
Fax | 239-345-7979
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9071 BONITA BEACH RD SE STE 1389
-----------------------------------------------------
City | BONITA SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34135-4213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-359-6475
-----------------------------------------------------
Fax | 239-359-6480
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | ME158521
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------