Basic Information
| Provider Information | |||||||||
| NPI: | 1962454736 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HA | ||||||||
| FirstName: | CUONG | ||||||||
| MiddleName: | GIA | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 9TH STREET | ||||||||
| Address2: | ROOM 205 MAILSTOP 2-3 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958146414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9166542431 | ||||||||
| FaxNumber: | 9166543186 | ||||||||
| Practice Location | |||||||||
| Address1: | 2501 HARBOR BLVD | ||||||||
| Address2: | |||||||||
| City: | COSTA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926266143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149575000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | A33582 | CA | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | AH8904824 | 01 | DEA | OTHER |