Provider Demographics
NPI:1174237150
Name:KHANH TAN DUONG MD PC
Entity type:Organization
Organization Name:KHANH TAN DUONG MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KHANH
Authorized Official - Middle Name:TAN
Authorized Official - Last Name:DUONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-255-0199
Mailing Address - Street 1:9635 MONTE VISTA AVE STE 208
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-2235
Mailing Address - Country:US
Mailing Address - Phone:909-255-0199
Mailing Address - Fax:216-208-1435
Practice Address - Street 1:9635 MONTE VISTA AVE STE 208
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763-2235
Practice Address - Country:US
Practice Address - Phone:909-255-0199
Practice Address - Fax:216-208-1435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-13
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care