Provider Demographics
NPI:1598742413
Name:HUYNH, PHI TAN (MD)
Entity Type:Individual
Prefix:
First Name:PHI
Middle Name:TAN
Last Name:HUYNH
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 1:1901 W KETTLEMAN LN
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-4337
Mailing Address - Country:US
Mailing Address - Phone:209-334-8540
Mailing Address - Fax:209-368-2885
Practice Address - Street 1:1901 W KETTLEMAN LN
Practice Address - Street 2:SUITE 200
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-4337
Practice Address - Country:US
Practice Address - Phone:209-334-8540
Practice Address - Fax:209-368-2885
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA91806207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5902228Medicaid
NC2048576Medicare ID - Type Unspecified
NC5902228Medicaid