MEDICARE: DR. XUANMAI THI TA O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	T2107	MN

General Provider Information

NPI Number	:	1003954033
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. XUANMAI THI TA O.D.

Provider Business Mailing Address
First Line	:	12167 CARTWAY CURV
Second Line	:
City	:	EDEN PRAIRIE
State	:	MN
Zip	:	55347-4254
Country	:	US
Telephone Number	:	612-871-1518
Fax Number	:	612-871-2525

Provider Business Practice Location Address
First Line	:	2718 NICOLLET AVE
Second Line	:	SUITE NO. 103
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-1648
Country	:	US
Telephone Number	:	612-871-1518
Fax Number	:	612-871-2585

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/02/2007
Last Update Date	:	03/13/2008

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