Provider Demographics
NPI:1174581052
Name:TRAN, DAN-TAM THI (MD)
Entity type:Individual
Prefix:
First Name:DAN-TAM
Middle Name:THI
Last Name:TRAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14810 OLD SAINT AUGUSTINE RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-2451
Mailing Address - Country:US
Mailing Address - Phone:904-268-7701
Mailing Address - Fax:904-268-9708
Practice Address - Street 1:14810 OLD SAINT AUGUSTINE RD
Practice Address - Street 2:SUITE 106
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258
Practice Address - Country:US
Practice Address - Phone:904-268-7701
Practice Address - Fax:904-268-9708
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME93753208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010756200Medicaid
FLU6429ZMedicare ID - Type Unspecified