Provider Demographics
NPI:1124370788
Name:LEVIN, PHUNG LIEU (DO)
Entity Type:Individual
Prefix:
First Name:PHUNG
Middle Name:LIEU
Last Name:LEVIN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 NEWINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21217-4631
Mailing Address - Country:US
Mailing Address - Phone:703-789-7753
Mailing Address - Fax:
Practice Address - Street 1:920 NEWINGTON AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21217-4631
Practice Address - Country:US
Practice Address - Phone:703-789-7753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-08
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC2-0013087207P00000X
OH34.012395207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0177676Medicaid
OHH473600Medicare PIN