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General NPI Number Information
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NPI Number | 1760721658
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Entity Type | Individual
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Provider Name | PHILONG VAN TA M.D.
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Gender | Male
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Dates
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Enumeration Date | 02/12/2013
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Last Update Date | 09/15/2014
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Provider Practice Location Address
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Address Line | 19468 EMPTY SADDLE RD
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City | WALNUT
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State | CA
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Zip | 91789-4290
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Country | US
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Telephone | 858-361-9116
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Fax |
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Provider Business Mailing Address
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Address Line | 19468 EMPTY SADDLE RD
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City | WALNUT
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State | CA
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Zip | 91789-4290
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Country | US
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Telephone | 858-361-9116
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | 129302
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | 272677-1
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License Number State | NY
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