Provider Demographics
NPI:1558661918
Name:PHUNG, SHU SHENG (OD)
Entity Type:Individual
Prefix:
First Name:SHU SHENG
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 1:2670 DEKALB AVE
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3110
Mailing Address - Country:US
Mailing Address - Phone:815-895-3937
Mailing Address - Fax:
Practice Address - Street 1:315 S CENTER ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-5101
Practice Address - Country:US
Practice Address - Phone:309-827-2337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-01
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.010355152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist