Provider Demographics
NPI:1568467140
Name:PHUNG, CHI HUU (MD)
Entity Type:Individual
Prefix:
First Name:CHI
Middle Name:HUU
Last Name:PHUNG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2514 E ALKI PL
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92806-5002
Mailing Address - Country:US
Mailing Address - Phone:714-817-8455
Mailing Address - Fax:714-537-9403
Practice Address - Street 1:2514 E. ALKI PL
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806-5002
Practice Address - Country:US
Practice Address - Phone:714-817-8455
Practice Address - Fax:714-537-9403
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64118B207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A641180Medicaid
CAG91917Medicare UPIN
CAWA64118BMedicare ID - Type Unspecified