Provider Demographics
NPI:1407130644
Name:PHUNG, ANH MY (OD)
Entity Type:Individual
Prefix:MS
First Name:ANH
Middle Name:MY
Last Name:PHUNG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 LYNDHURST WAY SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-2999
Mailing Address - Country:US
Mailing Address - Phone:770-891-0683
Mailing Address - Fax:
Practice Address - Street 1:1510 E FOWLER AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-5416
Practice Address - Country:US
Practice Address - Phone:813-971-0471
Practice Address - Fax:813-464-2763
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002670152W00000X
FLOPC5405152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021625600Medicaid