Provider Demographics
NPI:1710585633
Name:DAT N DUONG DO MEDICAL CORP
Entity Type:Organization
Organization Name:DAT N DUONG DO MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAT
Authorized Official - Middle Name:NGUYEN KHANH
Authorized Official - Last Name:DUONG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:586-604-2929
Mailing Address - Street 1:8610 CAPE CANAVERAL AVE
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-5046
Mailing Address - Country:US
Mailing Address - Phone:586-604-2929
Mailing Address - Fax:940-514-8085
Practice Address - Street 1:5451 LA PALMA AVE STE 32
Practice Address - Street 2:
Practice Address - City:LA PALMA
Practice Address - State:CA
Practice Address - Zip Code:90623-1731
Practice Address - Country:US
Practice Address - Phone:586-604-2929
Practice Address - Fax:940-514-8085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA938594Medicaid