Provider Demographics
NPI:1568537132
Name:TU N TRUONG M D A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:TU N TRUONG M D A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LIEU
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-536-3873
Mailing Address - Street 1:5069 EL CAJON BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-3348
Mailing Address - Country:US
Mailing Address - Phone:619-583-8705
Mailing Address - Fax:619-583-8701
Practice Address - Street 1:5069 EL CAJON BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-3348
Practice Address - Country:US
Practice Address - Phone:619-583-8705
Practice Address - Fax:619-583-8701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50756207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA654OtherCOMM HEALTH GRP
CA00A507561Medicaid
CA4575637OtherAETNA
CA310074OtherSD PHYSICIAN MED GRP
CA110244506OtherMEDICARE RAILROAD
CA00A50760OtherBLUE SHIELD CA
CA00A507561Medicaid
CA00A50760OtherBLUE SHIELD CA
CAF88082Medicare UPIN
CA=========92115A001OtherTRIWEST