=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891718318
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BO TAN HUYNH M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2006
-----------------------------------------------------
Last Update Date | 09/29/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2630 SAN GABRIEL BLVD STE 105
-----------------------------------------------------
City | ROSEMEAD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91770-5204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-288-2007
-----------------------------------------------------
Fax | 626-288-2116
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2630 SAN GABRIEL BLVD STE 105
-----------------------------------------------------
City | ROSEMEAD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91770-5204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-288-2007
-----------------------------------------------------
Fax | 626-288-2116
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | A87250
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------