1083147862 NPI number — KIET TUAN LA MD

Table of content: KIET TUAN LA MD (NPI 1083147862)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083147862 NPI number — KIET TUAN LA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LA
Provider First Name:
KIET
Provider Middle Name:
TUAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TRAN
Provider Other First Name:
KIET
Provider Other Middle Name:
TUAN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1083147862
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10987 SHELDON RD STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33626-4702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-467-4800
Provider Business Mailing Address Fax Number:
813-467-4252

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10987 SHELDON RD STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33626-4702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-467-4800
Provider Business Practice Location Address Fax Number:
813-467-4252
Provider Enumeration Date:
04/07/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: ME137806 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 104773500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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