Provider Demographics
NPI:1447315106
Name:TRUONG, THACH NGOC (MD)
Entity type:Individual
Prefix:
First Name:THACH
Middle Name:NGOC
Last Name:TRUONG
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 1:385 E MILL ST STE 13
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-1545
Mailing Address - Country:US
Mailing Address - Phone:909-383-0594
Mailing Address - Fax:909-381-2285
Practice Address - Street 1:385 E MILL ST STE 13
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-1545
Practice Address - Country:US
Practice Address - Phone:909-383-0594
Practice Address - Fax:909-381-2285
Is Sole Proprietor?:No
Enumeration Date:2006-12-23
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41638208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A416480Medicaid
00A416381Medicare PIN