Provider Demographics
NPI:1588969026
Name:MAI TUYET PHAN MEDICAL CLINIC A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:MAI TUYET PHAN MEDICAL CLINIC A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:
Authorized Official - First Name:MAI
Authorized Official - Middle Name:TUYET
Authorized Official - Last Name:PHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-342-8171
Mailing Address - Street 1:18625 SHERMAN WAY
Mailing Address - Street 2:SUITE 104
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-4148
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18625 SHERMAN WAY
Practice Address - Street 2:SUITE 104
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-4148
Practice Address - Country:US
Practice Address - Phone:818-342-8171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-13
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51466261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG02228Medicare UPIN