Provider Demographics
NPI:1376690024
Name:TRUONG, KENNETH TUONG THO (DO)
Entity type:Individual
Prefix:
First Name:KENNETH TUONG
Middle Name:THO
Last Name:TRUONG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33509 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94587-3203
Mailing Address - Country:US
Mailing Address - Phone:510-441-8600
Mailing Address - Fax:510-441-8686
Practice Address - Street 1:33509 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:CA
Practice Address - Zip Code:94587-3203
Practice Address - Country:US
Practice Address - Phone:510-441-8600
Practice Address - Fax:510-441-8686
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7327207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH25004Medicare UPIN
020A73270Medicare ID - Type Unspecified