Provider Demographics
NPI:1649833815
Name:DUONG, TRUNG TAN (MD)
Entity type:Individual
Prefix:
First Name:TRUNG
Middle Name:TAN
Last Name:DUONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JACK
Other - Middle Name:
Other - Last Name:DUONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 UCLA MEDICAL PLAZA
Practice Address - Street 2:SUITE 2200
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-8346
Practice Address - Country:US
Practice Address - Phone:310-825-9989
Practice Address - Fax:310-267-1908
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-15
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR772712084P0800X
CAA1839052084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry