Healthcare Provider Details

I. General information

NPI: 1326334186
Provider Name (Legal Business Name): DUY-BAO PHAN DINH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2011
Last Update Date: 12/27/2021
Certification Date: 12/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6810 S JUNIPER DR
OAK CREEK WI
53154-1631
US

IV. Provider business mailing address

6810 S JUNIPER DR
OAK CREEK WI
53154-1631
US

V. Phone/Fax

Practice location:
  • Phone: 703-509-4768
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMT200134
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number63713-20
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number63713-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: