Healthcare Provider Details

I. General information

NPI: 1629142062
Provider Name (Legal Business Name): ST. PAUL MEDICAL CLINIC A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2006
Last Update Date: 07/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15216 VANOWEN ST STE 2A
VAN NUYS CA
91405-3679
US

IV. Provider business mailing address

15216 VANOWEN ST STE 2A
VAN NUYS CA
91405-3679
US

V. Phone/Fax

Practice location:
  • Phone: 818-989-2406
  • Fax: 818-989-0696
Mailing address:
  • Phone: 818-989-2406
  • Fax: 818-989-0696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA90428
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberA90428
License Number StateCA

VIII. Authorized Official

Name: DR. ANHTUAN DANG TRAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 818-989-2406