Basic Information
| Provider Information | |||||||||
| NPI: | 1356364889 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUONG | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | T. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT. LA 23039 | ||||||||
| Address2: | ATTENTION: MAGGIE NOLES MS 6160 | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911853039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5623441150 | ||||||||
| FaxNumber: | 5623441155 | ||||||||
| Practice Location | |||||||||
| Address1: | 4540 E 7TH ST | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908044327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5623441150 | ||||||||
| FaxNumber: | 5623441155 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 03/29/2011 | ||||||||
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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 | 207R00000X | A66685 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A666850 | 05 | CA | MEDICAID | 00A666850 | 01 | BLUE SHIELD ID # | OTHER |