Provider Demographics
NPI:1174626840
Name:DANG, PHUNG T (MD)
Entity Type:Individual
Prefix:DR
First Name:PHUNG
Middle Name:T
Last Name:DANG
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 1:12414 STRATFORD RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6383
Mailing Address - Country:US
Mailing Address - Phone:314-277-2163
Mailing Address - Fax:
Practice Address - Street 1:12414 STRATFORD RIDGE CT
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6383
Practice Address - Country:US
Practice Address - Phone:314-277-2163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5G74225400000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOA10500Medicare UPIN
MO000000366Medicare ID - Type Unspecified