Healthcare Provider Details

I. General information

NPI: 1245434083
Provider Name (Legal Business Name): DAN VONGTAMA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 10/21/2022
Certification Date: 10/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4722 QUAIL LAKES DR
STOCKTON CA
95207-5256
US

IV. Provider business mailing address

4722 QUAIL LAKES DR
STOCKTON CA
95207-5256
US

V. Phone/Fax

Practice location:
  • Phone: 209-472-1848
  • Fax: 209-472-0133
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberA109003
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: