Healthcare Provider Details

I. General information

NPI: 1114371028
Provider Name (Legal Business Name): DIEP VUONG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2016
Last Update Date: 08/28/2023
Certification Date: 11/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11406 LOMA LINDA DR STE 516
LOMA LINDA CA
92354-3711
US

IV. Provider business mailing address

11234 ANDERSON ST GME OFFICE WESTERLY SUITE 'C'
LOMA LINDA CA
92354-2804
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-6204
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number1114371028
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number1114371028
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: