Healthcare Provider Details

I. General information

NPI: 1043969298
Provider Name (Legal Business Name): TONY KONG VANG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2022
Last Update Date: 11/11/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 MARKET PTE DR STE 100
BLOOMINGTON MN
55435-5435
US

IV. Provider business mailing address

1431 SW 1ST AVE
OCALA FL
34471-6500
US

V. Phone/Fax

Practice location:
  • Phone: 952-767-4574
  • Fax:
Mailing address:
  • Phone: 352-401-1417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberTRN36247
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: