Healthcare Provider Details

I. General information

NPI: 1639811425
Provider Name (Legal Business Name): ALEXANDER TRAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2022
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 NE GLEN OAK AVE
PEORIA IL
61637-0001
US

IV. Provider business mailing address

15671 EDEN ST
WESTMINSTER CA
92683-6828
US

V. Phone/Fax

Practice location:
  • Phone: 309-655-4940
  • Fax:
Mailing address:
  • Phone: 714-727-8895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1639811425
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: