Healthcare Provider Details

I. General information

NPI: 1396205092
Provider Name (Legal Business Name): MAI-ANH VUONG-DAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 08/05/2022
Certification Date: 08/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15725 WHITTIER BLVD STE 400
WHITTIER CA
90603-2338
US

IV. Provider business mailing address

15725 WHITTIER BLVD STE 400
WHITTIER CA
90603-2338
US

V. Phone/Fax

Practice location:
  • Phone: 562-947-1669
  • Fax: 562-464-5134
Mailing address:
  • Phone: 562-947-1669
  • Fax: 562-464-5134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA179403
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: