Provider Demographics
NPI:1205913654
Name:VO, PHAC VAN (MD)
Entity type:Individual
Prefix:
First Name:PHAC
Middle Name:VAN
Last Name:VO
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 1:611 EAST ANAHEIM STREET
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90813
Mailing Address - Country:US
Mailing Address - Phone:562-591-8982
Mailing Address - Fax:562-591-8180
Practice Address - Street 1:611 EAST ANAHEIM STREET
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813
Practice Address - Country:US
Practice Address - Phone:562-591-8982
Practice Address - Fax:562-591-8180
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43290208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A432900Medicaid
CA00A432900Medicaid
CAF15095Medicare UPIN