Provider Demographics
NPI:1649490038
Name:THAI, TUNG THANH
Entity type:Individual
Prefix:
First Name:TUNG
Middle Name:THANH
Last Name:THAI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10161 BOLSA AVE
Mailing Address - Street 2:SUITE 101-B
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-6768
Mailing Address - Country:US
Mailing Address - Phone:714-531-4100
Mailing Address - Fax:714-531-4700
Practice Address - Street 1:10161 BOLSA AVE
Practice Address - Street 2:SUITE 101-B
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-6768
Practice Address - Country:US
Practice Address - Phone:714-531-4100
Practice Address - Fax:714-531-4700
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA055970207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG59108Medicare UPIN
CAA55970AMedicare ID - Type Unspecified