Provider Demographics
NPI:1629142062
Name:ST. PAUL MEDICAL CLINIC A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:ST. PAUL MEDICAL CLINIC A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANHTUAN
Authorized Official - Middle Name:DANG
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-989-2406
Mailing Address - Street 1:15216 VANOWEN ST STE 2A
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-3679
Mailing Address - Country:US
Mailing Address - Phone:818-989-2406
Mailing Address - Fax:818-989-0696
Practice Address - Street 1:15216 VANOWEN ST STE 2A
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-3679
Practice Address - Country:US
Practice Address - Phone:818-989-2406
Practice Address - Fax:818-989-0696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-18
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA90428207R00000X, 261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A904280Medicaid
CAI48043Medicare UPIN
CA00A904280Medicaid