Healthcare Provider Details

I. General information

NPI: 1932217064
Provider Name (Legal Business Name): TAN PHUONG CAO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7487 S STATE ROAD 121
MACCLENNY FL
32063-5451
US

IV. Provider business mailing address

7487 S STATE ROAD 121
MACCLENNY FL
32063-5451
US

V. Phone/Fax

Practice location:
  • Phone: 904-259-6211
  • Fax: 904-259-7104
Mailing address:
  • Phone: 904-259-6211
  • Fax: 904-259-7104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME 45087
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: