Provider Demographics
NPI:1043792112
Name:THAO P PHUNG MD INC
Entity Type:Organization
Organization Name:THAO P PHUNG MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THAO
Authorized Official - Middle Name:
Authorized Official - Last Name:PHUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-483-6256
Mailing Address - Street 1:2913 EL CAMINO REAL STE 316
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92782-8909
Mailing Address - Country:US
Mailing Address - Phone:949-229-1153
Mailing Address - Fax:657-245-3168
Practice Address - Street 1:18035 BROOKHURST ST
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-6738
Practice Address - Country:US
Practice Address - Phone:310-483-6256
Practice Address - Fax:562-232-3728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-05
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA125932207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA125932Medicaid