Basic Information
| Provider Information | |||||||||
| NPI: | 1396056610 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUU | ||||||||
| FirstName: | TRI | ||||||||
| MiddleName: | THANH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5278 KESLING ST | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921173216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6198656437 | ||||||||
| FaxNumber: | 8445785606 | ||||||||
| Practice Location | |||||||||
| Address1: | 11234 ANDERSON ST STE C | ||||||||
| Address2: | |||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923542804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095588131 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2010 | ||||||||
| LastUpdateDate: | 03/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 052111 | NY | N | Pharmacy Service Providers | Pharmacist | 207R00000X | A126568 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208D00000X | A126568 | CA | N | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | A126568 | 05 | CA | MEDICAID |