Provider Demographics
NPI:1710475777
Name:TAI, NGUYEN DAN (MD)
Entity Type:Individual
Prefix:
First Name:NGUYEN
Middle Name:DAN
Last Name:TAI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21311 MADRONA AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-5970
Mailing Address - Country:US
Mailing Address - Phone:310-792-4041
Mailing Address - Fax:
Practice Address - Street 1:4101 TORRANCE BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-4607
Practice Address - Country:US
Practice Address - Phone:310-540-7676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-25
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA163882207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program