Provider Demographics
NPI:1891718318
Name:HUYNH, BO TAN (MD)
Entity Type:Individual
Prefix:DR
First Name:BO
Middle Name:TAN
Last Name:HUYNH
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 1:2630 SAN GABRIEL BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:ROSEMEAD
Mailing Address - State:CA
Mailing Address - Zip Code:91770-5204
Mailing Address - Country:US
Mailing Address - Phone:626-288-2007
Mailing Address - Fax:626-288-2116
Practice Address - Street 1:2630 SAN GABRIEL BLVD STE 105
Practice Address - Street 2:
Practice Address - City:ROSEMEAD
Practice Address - State:CA
Practice Address - Zip Code:91770-5204
Practice Address - Country:US
Practice Address - Phone:626-288-2007
Practice Address - Fax:626-288-2116
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA87250207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A872500Medicaid
CAWA87250BMedicare ID - Type UnspecifiedPPIN FOR GROUP W19595
CA00A872500Medicaid