Provider Demographics
NPI:1659765287
Name:PHANTHOK, TENZING (MD)
Entity Type:Individual
Prefix:
First Name:TENZING
Middle Name:
Last Name:PHANTHOK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 15TH ST STE BI1056
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30912-0004
Mailing Address - Country:US
Mailing Address - Phone:706-721-3813
Mailing Address - Fax:706-721-9286
Practice Address - Street 1:1500 OGLETHORPE AVE
Practice Address - Street 2:SUITE 200D
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2179
Practice Address - Country:US
Practice Address - Phone:706-389-3875
Practice Address - Fax:706-389-3876
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-20
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA81013207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program