Basic Information
Provider Information | |||||||||
NPI: | 1205063658 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | QUYEN HA MD PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 12883 | ||||||||
Address2: |   | ||||||||
City: | OKLAHOMA CITY | ||||||||
State: | OK | ||||||||
PostalCode: | 731572883 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4058580600 | ||||||||
FaxNumber: | 4058580602 | ||||||||
Practice Location | |||||||||
Address1: | 430 N MONTE VISTA ST | ||||||||
Address2: | VALLEY VIEW REG HOSPITAL WOUND CARE CENTER | ||||||||
City: | ADA | ||||||||
State: | OK | ||||||||
PostalCode: | 748204610 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5802721731 | ||||||||
FaxNumber: | 5802721720 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/12/2009 | ||||||||
LastUpdateDate: | 02/14/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HA | ||||||||
AuthorizedOfficialFirstName: | QUYEN | ||||||||
AuthorizedOfficialMiddleName: | THANH | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 5127999068 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 24063 | OK | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 200247790A | 05 | OK |   | MEDICAID |