Basic Information
Provider Information | |||||||||
NPI: | 1164403994 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DANG | ||||||||
FirstName: | THANH | ||||||||
MiddleName: | K | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DANG | ||||||||
OtherFirstName: | THANG | ||||||||
OtherMiddleName: | K | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 8170 33RD AVE S # MS 21110Q | ||||||||
Address2: |   | ||||||||
City: | MINNEAPOLIS | ||||||||
State: | MN | ||||||||
PostalCode: | 554254516 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1500 CURVE CREST BLVD W | ||||||||
Address2: |   | ||||||||
City: | STILLWATER | ||||||||
State: | MN | ||||||||
PostalCode: | 550826040 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6514391234 | ||||||||
FaxNumber: | 6512753325 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/09/2005 | ||||||||
LastUpdateDate: | 03/15/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/15/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 37961 | MN | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
ID | Type | State | Issuer | Description | 2116641 | 01 |   | FIRST HEALTH PLAN | OTHER | 130017755 | 01 |   | RR MEDICARE | OTHER | 785177 | 01 |   | ST CLOUD HOSPITAL | OTHER | 785177 | 01 |   | ARAZ GRP AMERICA'S PPO | OTHER | 1016683 | 01 |   | PREFERRED ONE | OTHER | 1507269 | 01 |   | MEDICA HEALTH PLANS | OTHER | HP26416 | 01 |   | HEALTH PARTNERS | OTHER | 122798 | 01 |   | U CARE | OTHER | 206518500 | 01 |   | MEDICAL ASSISTANCE | OTHER | 09 15 1998 | 01 |   | MMSI | OTHER | 45Q89DA | 01 |   | BLUE CROSS BLUE SHIELD | OTHER |