Provider Demographics
NPI:1942570130
Name:TYD EXECUTIVE MEDICAL CLINIC
Entity Type:Organization
Organization Name:TYD EXECUTIVE MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:TZE
Authorized Official - Middle Name:YU
Authorized Official - Last Name:DANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-500-0205
Mailing Address - Street 1:411 N CENTRAL AVE STE 305
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-2020
Mailing Address - Country:US
Mailing Address - Phone:818-500-0205
Mailing Address - Fax:818-500-1348
Practice Address - Street 1:411 N CENTRAL AVE STE 305
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-2020
Practice Address - Country:US
Practice Address - Phone:818-500-0205
Practice Address - Fax:818-500-1348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-05
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG44887261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG44887OtherMEDICAID
CA00G44887Medicaid
CA00G44887Medicaid