Provider Demographics
NPI:1194012161
Name:CUNG, TAM NHAT (DO)
Entity Type:Individual
Prefix:
First Name:TAM
Middle Name:NHAT
Last Name:CUNG
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 1:12200 PARK CENTRAL DR STE 110
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75251-2125
Mailing Address - Country:US
Mailing Address - Phone:972-701-0199
Mailing Address - Fax:972-701-0201
Practice Address - Street 1:1402 S CUSTER RD STE 401
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75072-1452
Practice Address - Country:US
Practice Address - Phone:469-714-0057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-29
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ5993207Q00000X
MI5101019571390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX360740002Medicaid