Provider Demographics
NPI:1306806096
Name:TRAN, TIEN MARK DUC (MD)
Entity type:Individual
Prefix:
First Name:TIEN MARK
Middle Name:DUC
Last Name:TRAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:TIEN
Other - Middle Name:DUC
Other - Last Name:TRAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1403 CHAMPIONS GREEN DR
Mailing Address - Street 2:SUITE #200
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32563-3575
Mailing Address - Country:US
Mailing Address - Phone:708-296-4986
Mailing Address - Fax:
Practice Address - Street 1:1403 CHAMPIONS GREEN DR
Practice Address - Street 2:SUITE #200
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32563-3575
Practice Address - Country:US
Practice Address - Phone:708-296-4986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-25
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90850207R00000X
CAA103175207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1033143045OtherMAIKA HEALTHCARE, LLC NPI NUMBER
FLME90850OtherFLORIDA LICENSURE
FL271356000Medicaid
FLME90850OtherFLORIDA LICENSURE
FLI16156Medicare UPIN
FL271356000Medicaid