Healthcare Provider Details

I. General information

NPI: 1184605628
Provider Name (Legal Business Name): MIMI TRINH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 01/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31001 RANCHO VIEJO RD SUITE 200
SAN JUAN CAPISTRANO CA
92675
US

IV. Provider business mailing address

17360 BROOKHURST ST ATTN: MCMF - CREDENTIALING DEPARTMENT
FOUNTAIN VALLEY CA
92708-3720
US

V. Phone/Fax

Practice location:
  • Phone: 949-661-9611
  • Fax: 949-443-6200
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA83342
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: