Provider Demographics
NPI:1487733788
Name:THAO, UMENG DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:UMENG
Middle Name:DAVID
Last Name:THAO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:DAVID
Other - Middle Name:
Other - Last Name:THAO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:604 BIELENBERG DR
Mailing Address - Street 2:SUITE 250
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-1414
Mailing Address - Country:US
Mailing Address - Phone:651-730-4100
Mailing Address - Fax:651-730-4107
Practice Address - Street 1:604 BIELENBERG DR
Practice Address - Street 2:SUITE 250
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-1414
Practice Address - Country:US
Practice Address - Phone:651-730-4100
Practice Address - Fax:651-730-4107
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN47379208200000X, 2082S0099X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN430093900Medicaid
MNI28480Medicare UPIN
MN430093900Medicaid