Provider Demographics
NPI:1518258268
Name:TRAN, ETHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:
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 1:26338 73RD AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:GLEN OAKS
Mailing Address - State:NY
Mailing Address - Zip Code:11004-1004
Mailing Address - Country:US
Mailing Address - Phone:408-600-4490
Mailing Address - Fax:
Practice Address - Street 1:26338 73RD AVE FL 2
Practice Address - Street 2:
Practice Address - City:GLEN OAKS
Practice Address - State:NY
Practice Address - Zip Code:11004-1004
Practice Address - Country:US
Practice Address - Phone:408-600-4490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-29
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261208-1207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8DG075OtherBCBS
TX1518258268OtherTRICARE SOUTH
TX302201402Medicaid
TX302201401Medicaid
TXTXB157776Medicare PIN
TXP01091220Medicare PIN
TXTXB157782Medicare PIN