Provider Demographics
NPI:1306020441
Name:VAN, TRUONG SON (MD)
Entity Type:Individual
Prefix:
First Name:TRUONG
Middle Name:SON
Last Name:VAN
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 1:312 S WASHINGTON ST
Mailing Address - Street 2:SUITE 2D
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-3684
Mailing Address - Country:US
Mailing Address - Phone:703-548-4300
Mailing Address - Fax:703-518-8949
Practice Address - Street 1:312 S WASHINGTON ST
Practice Address - Street 2:SUITE 2D
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-3684
Practice Address - Country:US
Practice Address - Phone:703-548-4300
Practice Address - Fax:703-518-8949
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-26
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101030692174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA121153Medicare PIN