Provider Demographics
NPI:1164457263
Name:WIRTHS, PHUONG T (DO)
Entity Type:Individual
Prefix:
First Name:PHUONG
Middle Name:T
Last Name:WIRTHS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 STATE ST
Mailing Address - Street 2:
Mailing Address - City:CURWENSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16833-1111
Mailing Address - Country:US
Mailing Address - Phone:814-236-3993
Mailing Address - Fax:814-236-3957
Practice Address - Street 1:605 STATE STREET
Practice Address - Street 2:
Practice Address - City:CURWENSVILLE
Practice Address - State:PA
Practice Address - Zip Code:16833-1111
Practice Address - Country:US
Practice Address - Phone:814-236-3993
Practice Address - Fax:814-236-3957
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS-009145-L207Q00000X
PAOS009145L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016982460Medicaid
PA001698246Medicaid
PA015073Medicare PIN
PAG78023Medicare UPIN