Healthcare Provider Details

I. General information

NPI: 1720007180
Provider Name (Legal Business Name): KEVIN LUAN VUONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 12/01/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11333 SEPULVEDA BLVD
MISSION HILLS CA
91345-1116
US

IV. Provider business mailing address

PO BOX 9602
MISSION HILLS CA
91346-9602
US

V. Phone/Fax

Practice location:
  • Phone: 818-365-9531
  • Fax:
Mailing address:
  • Phone: 818-837-5637
  • Fax: 818-837-5589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG79736
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: