Healthcare Provider Details

I. General information

NPI: 1538302351
Provider Name (Legal Business Name): CANCER AND BLOOD SPECIALTY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2009
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3822 KATELLA AVE
LOS ALAMITOS CA
90720-3302
US

IV. Provider business mailing address

P O BOX 743752 LOS ANGELES CA 90074-3752
LOS ANGELES CA
90074-3752
US

V. Phone/Fax

Practice location:
  • Phone: 627-254-3675
  • Fax: 562-725-4369
Mailing address:
  • Phone: 562-725-4367
  • Fax: 562-725-4369

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA70377
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberA70377
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code261QX0200X
TaxonomyOncology Clinic/Center
License NumberA70377
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code261QX0200X
TaxonomyOncology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. VU Q PHAN
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 562-725-4367