Provider Demographics
NPI:1750769840
Name:TRAN, KHOI TAN NGUYEN (DO)
Entity type:Individual
Prefix:
First Name:KHOI
Middle Name:TAN NGUYEN
Last Name:TRAN
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 1:252 MATLOCK RD STE 130
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-4295
Mailing Address - Country:US
Mailing Address - Phone:682-242-8990
Mailing Address - Fax:682-242-8996
Practice Address - Street 1:252 MATLOCK RD STE 130
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-4295
Practice Address - Country:US
Practice Address - Phone:682-242-8990
Practice Address - Fax:682-242-8996
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-11
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXU8147207Q00000X
390200000X
TN3563207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ044693Medicaid
TNPENDINGMedicaid