=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407077829
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIEM THI TRINH MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2007
-----------------------------------------------------
Last Update Date | 11/30/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 250 W 57TH ST SUITE 825
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10107-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-489-6669
-----------------------------------------------------
Fax | 212-265-7685
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6620 108TH ST APT 2M
-----------------------------------------------------
City | FOREST HILLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11375-2251
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-459-5916
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | 210834
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------