Provider Demographics
NPI:1073293403
Name:DUONG, KHA PHAN
Entity Type:Individual
Prefix:
First Name:KHA
Middle Name:PHAN
Last Name:DUONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217-2 CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210
Mailing Address - Country:US
Mailing Address - Phone:321-806-6466
Mailing Address - Fax:
Practice Address - Street 1:3409 ERIE BLVD E UNIT 200
Practice Address - Street 2:
Practice Address - City:DEWITT
Practice Address - State:NY
Practice Address - Zip Code:13214
Practice Address - Country:US
Practice Address - Phone:315-446-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-20
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009864152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist