Provider Demographics
NPI:1083697007
Name:PHENG, SOTHY LUN (MD)
Entity Type:Individual
Prefix:
First Name:SOTHY
Middle Name:LUN
Last Name:PHENG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3446
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92834-3446
Mailing Address - Country:US
Mailing Address - Phone:978-551-8088
Mailing Address - Fax:
Practice Address - Street 1:2961 OAKBERRY CT
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-4304
Practice Address - Country:US
Practice Address - Phone:978-551-8088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA220489207R00000X
CAC132666207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2086948Medicaid
I20201Medicare UPIN
MAA37853Medicare ID - Type Unspecified