Provider Demographics
NPI:1861415390
Name:TA, VIET D (MD)
Entity type:Individual
Prefix:
First Name:VIET
Middle Name:D
Last Name:TA
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 1:8235 ROCHESTER AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-0718
Mailing Address - Country:US
Mailing Address - Phone:909-484-4900
Mailing Address - Fax:909-243-7868
Practice Address - Street 1:8235 ROCHESTER AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-0718
Practice Address - Country:US
Practice Address - Phone:909-484-4900
Practice Address - Fax:909-243-7868
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA69957207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A699570OtherBLUE SHIELD
CA00A699570Medicaid
CA00A699570OtherBLUE SHIELD
CA00A699570Medicaid