Healthcare Provider Details

I. General information

NPI: 1174581052
Provider Name (Legal Business Name): DAN-TAM THI TRAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 10/27/2021
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14810 OLD SAINT AUGUSTINE RD SUITE 106
JACKSONVILLE FL
32258
US

IV. Provider business mailing address

14810 OLD SAINT AUGUSTINE RD SUITE 106
JACKSONVILLE FL
32258-2451
US

V. Phone/Fax

Practice location:
  • Phone: 904-268-7701
  • Fax: 904-268-9708
Mailing address:
  • Phone: 904-268-7701
  • Fax: 904-268-9708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME93753
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: