Provider Demographics
NPI:1710081047
Name:PHAN, TUAN VAN (MD)
Entity Type:Individual
Prefix:MR
First Name:TUAN
Middle Name:VAN
Last Name:PHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1569 LEXANN AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95121-1794
Mailing Address - Country:US
Mailing Address - Phone:408-270-4267
Mailing Address - Fax:408-270-3594
Practice Address - Street 1:1569 LEXANN AVE STE 120
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95121-1794
Practice Address - Country:US
Practice Address - Phone:408-270-4267
Practice Address - Fax:408-270-3594
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51069207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A510690Medicaid
CA00A510690Medicaid
CA00A510690Medicare ID - Type Unspecified