Provider Demographics
NPI:1992724512
Name:TRUONG, MAI KIM DAN (DPM)
Entity type:Individual
Prefix:
First Name:MAI
Middle Name:KIM DAN
Last Name:TRUONG
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 PERRY AVE
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-1826
Mailing Address - Country:US
Mailing Address - Phone:714-588-9860
Mailing Address - Fax:
Practice Address - Street 1:17215 STUDEBAKER RD STE 108
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-2521
Practice Address - Country:US
Practice Address - Phone:310-750-4511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4424213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU99047Medicare UPIN