Basic Information
Provider Information | |||||||||
NPI: | 1932272614 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DANG | ||||||||
FirstName: | PHONG | ||||||||
MiddleName: | T | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 775 | ||||||||
Address2: |   | ||||||||
City: | GARDEN GROVE | ||||||||
State: | CA | ||||||||
PostalCode: | 928420775 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7146360342 | ||||||||
FaxNumber: | 7146360391 | ||||||||
Practice Location | |||||||||
Address1: | 12900A GARDEN GROVE BLVD | ||||||||
Address2: | STE #122 | ||||||||
City: | GARDEN GROVE | ||||||||
State: | CA | ||||||||
PostalCode: | 928432023 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7146360342 | ||||||||
FaxNumber: | 7146360391 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/17/2006 | ||||||||
LastUpdateDate: | 12/03/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | G78903 | CA | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 050068278 | 01 | CA | RAILROAD MEDICARE | OTHER | OOG789030 | 05 | CA |   | MEDICAID |