Provider Demographics
NPI:1356640601
Name:PHAN, PETER-TRUNG DUC (MD)
Entity Type:Individual
Prefix:
First Name:PETER-TRUNG
Middle Name:DUC
Last Name:PHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:PETER
Other - Middle Name:
Other - Last Name:PHAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1849 LAKE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35216-1619
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 19TH ST S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-1927
Practice Address - Country:US
Practice Address - Phone:205-933-8101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-24
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL33401207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine