Provider Demographics
NPI:1073928594
Name:LUU, PHONG (DO)
Entity Type:Individual
Prefix:DR
First Name:PHONG
Middle Name:
Last Name:LUU
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 1:5404 SW LEE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-9695
Mailing Address - Country:US
Mailing Address - Phone:580-355-5242
Mailing Address - Fax:
Practice Address - Street 1:5404 SW LEE BLVD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-9695
Practice Address - Country:US
Practice Address - Phone:580-355-5242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-23
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OK5772207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program