Provider Demographics
NPI:1184809329
Name:BAO CONG TRAN MD INC
Entity type:Organization
Organization Name:BAO CONG TRAN MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF THE CORPORATION
Authorized Official - Prefix:
Authorized Official - First Name:BAO
Authorized Official - Middle Name:CONG
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-593-3388
Mailing Address - Street 1:175 W LA VERNE AVE
Mailing Address - Street 2:#D
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91676-2332
Mailing Address - Country:US
Mailing Address - Phone:909-593-3388
Mailing Address - Fax:909-596-0518
Practice Address - Street 1:175 W LA VERNE AVE
Practice Address - Street 2:#D
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91676-2332
Practice Address - Country:US
Practice Address - Phone:909-593-3388
Practice Address - Fax:909-596-0518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-07
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41661207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0087500Medicaid
CAGR0087500Medicaid
CAW14770Medicare PIN