Provider Demographics
NPI:1114318151
Name:PHONG, CECILIA (MD)
Entity Type:Individual
Prefix:
First Name:CECILIA
Middle Name:
Last Name:PHONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 SAN BERNARDINO RD STE 201
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4985
Mailing Address - Country:US
Mailing Address - Phone:909-579-0806
Mailing Address - Fax:
Practice Address - Street 1:1310 SAN BERNARDINO RD STE 201
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4985
Practice Address - Country:US
Practice Address - Phone:909-579-0806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-12
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA139142207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program