Provider Demographics
NPI:1124336839
Name:VAN, CHINH VIEN (MD)
Entity type:Individual
Prefix:
First Name:CHINH
Middle Name:VIEN
Last Name:VAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1005 MAR WALT DRIVE
Mailing Address - Street 2:IMMEDIATE CARE DEPARTMENT
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6796
Mailing Address - Country:US
Mailing Address - Phone:850-863-8219
Mailing Address - Fax:850-863-8249
Practice Address - Street 1:1005 MAR WALT DRIVE
Practice Address - Street 2:IMMEDIATE CARE DEPARTMENT
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6796
Practice Address - Country:US
Practice Address - Phone:850-863-8219
Practice Address - Fax:850-863-8249
Is Sole Proprietor?:No
Enumeration Date:2010-09-15
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME112971207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14L8LOtherBCBSFL
FL005580200Medicaid
FLGK821ZMedicare PIN