Provider Demographics
NPI:1457310211
Name:TRAN, BAO CONG (MD)
Entity Type:Individual
Prefix:
First Name:BAO
Middle Name:CONG
Last Name:TRAN
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 1:175 W LAVERNE AVE
Mailing Address - Street 2:D
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-2332
Mailing Address - Country:US
Mailing Address - Phone:909-593-3388
Mailing Address - Fax:909-596-0518
Practice Address - Street 1:175 W LAVERNE AVE
Practice Address - Street 2:D
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-2332
Practice Address - Country:US
Practice Address - Phone:909-593-3388
Practice Address - Fax:909-596-0518
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41661207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A416610Medicaid
CAGF0087500Medicaid
CAW14770Medicare ID - Type Unspecified
CA00A416610Medicaid
CAGF0087500Medicaid