Basic Information
| Provider Information | |||||||||
| NPI: | 1265651632 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOANG | ||||||||
| FirstName: | JOHN | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5410 MARYLAND WAY | ||||||||
| Address2: | 300 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153775600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2101 N WATERMAN AVE | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924044836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098814520 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2007 | ||||||||
| LastUpdateDate: | 11/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 20A9427 | CA | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 20A9427 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 020A94270 | 01 | CA | BLUE SHIELD | OTHER |