Provider Demographics
NPI:1477716827
Name:PHUNG, THAO LY (OD)
Entity Type:Individual
Prefix:DR
First Name:THAO LY
Middle Name:
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 1:3624 HIGHWAY 365
Mailing Address - Street 2:
Mailing Address - City:NEDERLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77627-7835
Mailing Address - Country:US
Mailing Address - Phone:409-724-7700
Mailing Address - Fax:409-724-7703
Practice Address - Street 1:3624 HIGHWAY 365
Practice Address - Street 2:
Practice Address - City:NEDERLAND
Practice Address - State:TX
Practice Address - Zip Code:77627-7835
Practice Address - Country:US
Practice Address - Phone:409-724-7700
Practice Address - Fax:409-724-7703
Is Sole Proprietor?:No
Enumeration Date:2008-07-07
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7245TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB105840Medicare PIN