Provider Demographics
NPI:1194991430
Name:TRAN, KHANG VAN
Entity type:Individual
Prefix:DR
First Name:KHANG
Middle Name:VAN
Last Name:TRAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:KHANG
Other - Middle Name:VAN
Other - Last Name:TRAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD INC
Mailing Address - Street 1:4616 EL CAJON BLVD
Mailing Address - Street 2:SUITE 9
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-4426
Mailing Address - Country:US
Mailing Address - Phone:619-280-4616
Mailing Address - Fax:619-280-4617
Practice Address - Street 1:4616 EL CAJON BLVD
Practice Address - Street 2:SUITE 9
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-4426
Practice Address - Country:US
Practice Address - Phone:619-280-4616
Practice Address - Fax:619-280-4617
Is Sole Proprietor?:No
Enumeration Date:2008-05-06
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33941207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA33941Medicaid
CAE01803Medicare UPIN
CAA33941Medicaid