Provider Demographics
NPI:1174693881
Name:KEVIN KHAI TIEU M D A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:KEVIN KHAI TIEU M D A PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT MD
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN KHAI
Authorized Official - Middle Name:TUAN
Authorized Official - Last Name:TIEU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-418-9749
Mailing Address - Street 1:16543 BROOKHURST ST
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-2343
Mailing Address - Country:US
Mailing Address - Phone:714-418-9749
Mailing Address - Fax:714-418-1047
Practice Address - Street 1:16543 BROOKHURST ST
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-2343
Practice Address - Country:US
Practice Address - Phone:714-418-9749
Practice Address - Fax:714-418-1047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA77268207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A772680Medicaid
CA00A772680Medicaid
CAA77268Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER