Provider Demographics
NPI:1043567407
Name:PHAN, PHUNG DINH (DO)
Entity Type:Individual
Prefix:DR
First Name:PHUNG
Middle Name:DINH
Last Name:PHAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:UNIT 28038 BLD 700
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09112
Mailing Address - Country:US
Mailing Address - Phone:314-590-3904
Mailing Address - Fax:
Practice Address - Street 1:UNIT 28130, BUILDING 475
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09114
Practice Address - Country:US
Practice Address - Phone:314-590-3176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-04
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1141171000000X, 207Q00000X, 171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No171000000XOther Service ProvidersMilitary Health Care Provider