Provider Demographics
NPI:1083662886
Name:TRUONG, THANH T (MD)
Entity Type:Individual
Prefix:
First Name:THANH
Middle Name:T
Last Name:TRUONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5126 BUTLER WARREN RD
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-1241
Mailing Address - Country:US
Mailing Address - Phone:513-459-2839
Mailing Address - Fax:513-459-0242
Practice Address - Street 1:5126 BUTLER WARREN RD
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-1241
Practice Address - Country:US
Practice Address - Phone:513-459-2839
Practice Address - Fax:513-459-0242
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.072785208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2091749Medicaid