MEDICARE: DAN VONGTAMA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0001X	Radiation Oncology Physician	A109003	CA

General Provider Information

NPI Number	:	1245434083
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAN VONGTAMA M.D.

Provider Business Mailing Address
First Line	:	4722 QUAIL LAKES DR
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95207-5256
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4722 QUAIL LAKES DR
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95207-5256
Country	:	US
Telephone Number	:	209-472-1848
Fax Number	:	209-472-0133

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2007
Last Update Date	:	10/21/2022

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