Provider Demographics
NPI:1770674558
Name:PHUNG, JOHN (DC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:PHUNG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 N GARLAND AVE
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75040-5646
Mailing Address - Country:US
Mailing Address - Phone:214-703-0044
Mailing Address - Fax:214-703-0691
Practice Address - Street 1:417 N GARLAND AVE
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75040-5646
Practice Address - Country:US
Practice Address - Phone:214-703-0044
Practice Address - Fax:214-703-0691
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9764111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1762254Medicaid
TX1762254Medicaid
TX8D1162Medicare ID - Type Unspecified