Provider Demographics
NPI:1578564241
Name:PHAN, CUONG Q (MD)
Entity Type:Individual
Prefix:
First Name:CUONG
Middle Name:Q
Last Name:PHAN
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 1:25511 BUDDE RD STE 1201
Mailing Address - Street 2:BELLE BUILDING
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77380-2091
Mailing Address - Country:US
Mailing Address - Phone:281-364-1707
Mailing Address - Fax:281-364-0028
Practice Address - Street 1:25511 BUDDE RD STE 1201
Practice Address - Street 2:BELLE BUILDING
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77380-2091
Practice Address - Country:US
Practice Address - Phone:281-364-1707
Practice Address - Fax:281-364-0028
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY39212174400000X
174400000X
TXM36912085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1590648-01OtherGROUP MEDICAID
TX00250TOtherGROUP MEDICARE PIN
TX00251TOtherGROUP MEDICARE PIN
TX1590473-01OtherGROUP MEDICAID
TX8L26797Medicare PIN
TX8L23696Medicare PIN
TXI29889Medicare UPIN
TX1590473-01OtherGROUP MEDICAID
OA5184Medicare PIN
TX8F8310Medicare PIN
TX00250TOtherGROUP MEDICARE PIN