Provider Demographics
NPI:1801840483
Name:TRUONG, THAN VAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:THAN
Middle Name:VAN
Last Name:TRUONG
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16171 BROOKHURST ST
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-1550
Mailing Address - Country:US
Mailing Address - Phone:714-531-1434
Mailing Address - Fax:310-675-0904
Practice Address - Street 1:16171 BROOKHURST ST
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-1550
Practice Address - Country:US
Practice Address - Phone:714-531-1434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4636213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
W17007OtherMEDICARE GROUP
CABO152YOtherMEDICARE PTAN
CAGRE001780Medicaid
CABO152YOtherMEDICARE PTAN