Basic Information
| Provider Information | |||||||||
| NPI: | 1417335134 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LA | ||||||||
| FirstName: | VAN | ||||||||
| MiddleName: | TIEU | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 S. 1ST ST. #101 | ||||||||
| Address2: | |||||||||
| City: | ALHAMBRA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9514864397 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 220 S. 1ST ST. #101 | ||||||||
| Address2: | |||||||||
| City: | ALHAMBRA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262818663 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2015 | ||||||||
| LastUpdateDate: | 10/14/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 10/04/2022 | ||||||||
| NPIReactivationDate: | 10/13/2022 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 20A15659 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207R00000X | 20A15659 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.