Provider Demographics
NPI:1245434083
Name:VONGTAMA, DAN (MD)
Entity type:Individual
Prefix:
First Name:DAN
Middle Name:
Last Name:VONGTAMA
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 1:4722 QUAIL LAKES DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-5256
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4722 QUAIL LAKES DR
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5256
Practice Address - Country:US
Practice Address - Phone:209-472-1848
Practice Address - Fax:209-472-0133
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1090032085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology