Provider Demographics
NPI:1760721658
Name:TA, PHILONG VAN (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILONG
Middle Name:VAN
Last Name:TA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19468 EMPTY SADDLE RD
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-4290
Mailing Address - Country:US
Mailing Address - Phone:858-361-9116
Mailing Address - Fax:
Practice Address - Street 1:19468 EMPTY SADDLE RD
Practice Address - Street 2:
Practice Address - City:WALNUT
Practice Address - State:CA
Practice Address - Zip Code:91789-4290
Practice Address - Country:US
Practice Address - Phone:858-361-9116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-12
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA129302207L00000X
NY272677-1207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology