Provider Demographics
NPI:1407495815
Name:SOTHY L PHENG MD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:SOTHY L PHENG MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SOTHY
Authorized Official - Middle Name:LUN
Authorized Official - Last Name:PHENG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:978-551-8088
Mailing Address - Street 1:PO BOX 3446
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92834-3446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2961 OAKBERRY CT
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-4304
Practice Address - Country:US
Practice Address - Phone:978-551-8088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-02
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2086948Medicaid