=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093918872
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHU VAN DANG, MD & PAULINE SUONG THI DANG, MD, A PROF MEDICAL CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2007
-----------------------------------------------------
Last Update Date | 05/20/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13872 HARBOR BLVD UNIT 1C
-----------------------------------------------------
City | GARDEN GROVE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92843-4000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-531-5201
-----------------------------------------------------
Fax | 714-775-2849
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13872 HARBOR BLVD UNIT 1C
-----------------------------------------------------
City | GARDEN GROVE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92843-4000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-531-5201
-----------------------------------------------------
Fax | 714-775-2849
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. PHU VAN DANG
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 714-531-5201
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | A41591
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | A42349
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number | A65421
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------