Provider Demographics
NPI:1609121714
Name:DANG, MINH
Entity Type:Individual
Prefix:
First Name:MINH
Middle Name:
Last Name:DANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8528 LINE AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-6144
Mailing Address - Country:US
Mailing Address - Phone:318-869-0669
Mailing Address - Fax:318-869-0671
Practice Address - Street 1:8528 LINE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-6144
Practice Address - Country:US
Practice Address - Phone:318-869-0669
Practice Address - Fax:318-869-0671
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA16214183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1263192Medicaid