Provider Demographics
NPI:1841188810
Name:T. VAN, MD PROF. MEDICAL CORP.
Entity type:Organization
Organization Name:T. VAN, MD PROF. MEDICAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:THIEN
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-255-9311
Mailing Address - Street 1:1016 N D ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92410-3522
Mailing Address - Country:US
Mailing Address - Phone:626-255-9311
Mailing Address - Fax:909-752-5245
Practice Address - Street 1:1016 N D ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92410-3522
Practice Address - Country:US
Practice Address - Phone:626-255-9311
Practice Address - Fax:909-752-5245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-26
Last Update Date:2025-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care