Basic Information
| Provider Information | |||||||||
| NPI: | 1184609885 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TRAN | ||||||||
| FirstName: | PHONG | ||||||||
| MiddleName: | HUNG | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9658 | ||||||||
| Address2: | |||||||||
| City: | FOUNTAIN VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927289005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145317730 | ||||||||
| FaxNumber: | 7145317793 | ||||||||
| Practice Location | |||||||||
| Address1: | 15606 BROOKHURST ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | WESTMINSTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926837581 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145317730 | ||||||||
| FaxNumber: | 7145317793 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2005 | ||||||||
| LastUpdateDate: | 12/03/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | G74233 | CA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | WG74233B | 01 | CA | PTAN | OTHER |