Provider Demographics
NPI:1144212713
Name:PHUNG, STEVE (OD)
Entity Type:Individual
Prefix:
First Name:STEVE
Middle Name:
Last Name:PHUNG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11412 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90606-3122
Mailing Address - Country:US
Mailing Address - Phone:562-908-0510
Mailing Address - Fax:562-908-0511
Practice Address - Street 1:11412 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90606-3122
Practice Address - Country:US
Practice Address - Phone:562-908-0510
Practice Address - Fax:562-908-0511
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11097T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAV936YOtherMEDICARE PTAN
CASD0110972Medicaid
CAU73507Medicare UPIN
CASD0110972Medicaid