Healthcare Provider Details

I. General information

NPI: 1528042090
Provider Name (Legal Business Name): VIET QUOC MAI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 W BADILLO ST SUITE E
COVINA CA
91722-3762
US

IV. Provider business mailing address

1446 SUMMITRIDGE DR
DIAMOND BAR CA
91765-4331
US

V. Phone/Fax

Practice location:
  • Phone: 626-858-5730
  • Fax: 626-966-0430
Mailing address:
  • Phone: 909-861-1582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA82432
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: