Provider Demographics
NPI:1184645020
Name:PHUNG, MAI T (DO)
Entity Type:Individual
Prefix:
First Name:MAI
Middle Name:T
Last Name:PHUNG
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 1:1910 W ROYALE DR
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-2264
Mailing Address - Country:US
Mailing Address - Phone:765-289-1011
Mailing Address - Fax:765-289-3024
Practice Address - Street 1:1910 W ROYALE DR
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-2264
Practice Address - Country:US
Practice Address - Phone:765-289-1011
Practice Address - Fax:765-289-3024
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002307A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200348480AMedicaid
IN219900Medicare ID - Type Unspecified
INH16934Medicare UPIN