Provider Demographics
NPI:1508972365
Name:DANG, HAI VAN (MD)
Entity Type:Individual
Prefix:
First Name:HAI
Middle Name:VAN
Last Name:DANG
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:PO BOX 410
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-0005
Mailing Address - Country:US
Mailing Address - Phone:662-349-3355
Mailing Address - Fax:662-349-8815
Practice Address - Street 1:7640 CLARINGTON CV
Practice Address - Street 2:SUITE B
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-5652
Practice Address - Country:US
Practice Address - Phone:662-349-3355
Practice Address - Fax:662-349-8815
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13499174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0114919Medicaid