Provider Demographics
NPI:1821618661
Name:VAN, THANH CONG (DPM)
Entity Type:Individual
Prefix:DR
First Name:THANH
Middle Name:CONG
Last Name:VAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:DR
Other - First Name:THOMAS
Other - Middle Name:CONG
Other - Last Name:VAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:2724 N HIAWASSEE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32818-3003
Mailing Address - Country:US
Mailing Address - Phone:407-906-0082
Mailing Address - Fax:407-604-2606
Practice Address - Street 1:2724 N HIAWASSEE RD STE 100
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32818-3003
Practice Address - Country:US
Practice Address - Phone:407-906-0082
Practice Address - Fax:407-604-2606
Is Sole Proprietor?:No
Enumeration Date:2020-04-22
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO4368213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist