Basic Information
Provider Information | |||||||||
NPI: | 1740357565 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DANG | ||||||||
FirstName: | CHUONG MICHAEL | ||||||||
MiddleName: | VAN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DANG | ||||||||
OtherFirstName: | C MICHAEL | ||||||||
OtherMiddleName: | V | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 393 E WALNUT ST | ||||||||
Address2: | PHR GROUP PROVIDER ENROLLMENT UNIT 3RD FL | ||||||||
City: | PASADENA | ||||||||
State: | CA | ||||||||
PostalCode: | 911880001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8776080044 | ||||||||
FaxNumber: | 8775140903 | ||||||||
Practice Location | |||||||||
Address1: | 9961 SIERRA AVE | ||||||||
Address2: |   | ||||||||
City: | FONTANA | ||||||||
State: | CA | ||||||||
PostalCode: | 923356720 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9094277650 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/29/2006 | ||||||||
LastUpdateDate: | 12/21/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/21/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | G63728 | CA | Y |   | Allopathic & Osteopathic Physicians | Radiology | Body Imaging |
No ID Information.