Basic Information
| Provider Information | |||||||||
| NPI: | 1174581052 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TRAN | ||||||||
| FirstName: | DAN-TAM | ||||||||
| MiddleName: | THI | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14810 OLD SAINT AUGUSTINE RD | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322582451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042687701 | ||||||||
| FaxNumber: | 9042689708 | ||||||||
| Practice Location | |||||||||
| Address1: | 14810 OLD SAINT AUGUSTINE RD | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042687701 | ||||||||
| FaxNumber: | 9042689708 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 10/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME93753 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 010756200 | 05 | FL | MEDICAID |