Provider Demographics
NPI:1811347198
Name:TRAN, PHUC-BAO (DO)
Entity type:Individual
Prefix:DR
First Name:PHUC-BAO
Middle Name:
Last Name:TRAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22921 ESTORIL DR
Mailing Address - Street 2:UNIT #3
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-5407
Mailing Address - Country:US
Mailing Address - Phone:517-281-5926
Mailing Address - Fax:
Practice Address - Street 1:2592 N SANTIAGO BLVD
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92867-1862
Practice Address - Country:US
Practice Address - Phone:714-577-2271
Practice Address - Fax:949-281-5550
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A16282207Q00000X
390200000X
CACA20A16282207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program