Provider Demographics
NPI:1669580064
Name:TRAN, THUC BAO THI (MD)
Entity type:Individual
Prefix:
First Name:THUC
Middle Name:BAO 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 1:13031 KERRY ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92844-1638
Mailing Address - Country:US
Mailing Address - Phone:714-786-6652
Mailing Address - Fax:985-635-4132
Practice Address - Street 1:13031 KERRY ST
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92844
Practice Address - Country:US
Practice Address - Phone:714-786-6652
Practice Address - Fax:985-635-4132
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-26
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA024867207V00000X
CAC139269207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1577715Medicaid
I26534Medicare UPIN
LA4K071/CT85Medicare ID - Type Unspecified