Provider Demographics
NPI:1164422267
Name:TRAN, PHUONG - THI NGOC (DO)
Entity Type:Individual
Prefix:
First Name:PHUONG - THI
Middle Name:NGOC
Last Name:TRAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 S WOODLAND ST
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-3546
Mailing Address - Country:US
Mailing Address - Phone:407-905-8827
Mailing Address - Fax:352-360-2389
Practice Address - Street 1:225 N 1ST ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5150
Practice Address - Country:US
Practice Address - Phone:407-905-8827
Practice Address - Fax:352-360-2389
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9107207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270414500Medicaid
FL48616YMedicare PIN
I16602Medicare UPIN