Provider Demographics
NPI:1093918872
Name:PHU VAN DANG, MD & PAULINE SUONG THI DANG, MD, A PROF MEDICAL CORP
Entity Type:Organization
Organization Name:PHU VAN DANG, MD & PAULINE SUONG THI DANG, MD, A PROF MEDICAL CORP
Other - Org Name:BOLSA-WARD MEDICAL CLINIC, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PHU
Authorized Official - Middle Name:VAN
Authorized Official - Last Name:DANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-531-5201
Mailing Address - Street 1:13872 HARBOR BLVD
Mailing Address - Street 2:UNIT 1C
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-4000
Mailing Address - Country:US
Mailing Address - Phone:714-531-5201
Mailing Address - Fax:714-775-2849
Practice Address - Street 1:13872 HARBOR BLVD
Practice Address - Street 2:UNIT 1C
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-4000
Practice Address - Country:US
Practice Address - Phone:714-531-5201
Practice Address - Fax:714-775-2849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41591207Q00000X
CAA42349207Q00000X
CAA65421207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW13435Medicare ID - Type Unspecified