Provider Demographics
NPI:1386778033
Name:PHAN, CONG THANH (MD)
Entity type:Individual
Prefix:DR
First Name:CONG
Middle Name:THANH
Last Name:PHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8235 ROCHESTER AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-0719
Mailing Address - Country:US
Mailing Address - Phone:909-484-4900
Mailing Address - Fax:
Practice Address - Street 1:8235 ROCHESTER AVE STE 110
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-0719
Practice Address - Country:US
Practice Address - Phone:909-484-4900
Practice Address - Fax:909-781-2949
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
00A780920174400000X
CAA780920207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI08344Medicare UPIN
CAZZZ05347ZMedicare PIN