Provider Demographics
NPI:1790245256
Name:HO, SOPHIA PHUONG (DO)
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:PHUONG
Last Name:HO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:PHUONG
Other - Middle Name:BAO
Other - Last Name:HO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:32604 CAMINITO ROSADA
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-1263
Mailing Address - Country:US
Mailing Address - Phone:714-417-4452
Mailing Address - Fax:
Practice Address - Street 1:111 N SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-6861
Practice Address - Country:US
Practice Address - Phone:310-409-8548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A19502207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program