Provider Demographics
NPI:1528022563
Name:DUONG, TAI (DO)
Entity Type:Individual
Prefix:
First Name:TAI
Middle Name:
Last Name:DUONG
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 1:1101 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-1528
Mailing Address - Country:US
Mailing Address - Phone:574-753-1475
Mailing Address - Fax:
Practice Address - Street 1:1907 W SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901-5148
Practice Address - Country:US
Practice Address - Phone:765-456-5733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002208A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200239830Medicaid
IN200239830Medicaid
152680FFMedicare ID - Type Unspecified