Provider Demographics
NPI:1841225224
Name:BUI, MARY PHUONG
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:PHUONG
Last Name:BUI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1869
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91785-1869
Mailing Address - Country:US
Mailing Address - Phone:909-981-5882
Mailing Address - Fax:909-385-0379
Practice Address - Street 1:1317 W FOOTHILL BLVD
Practice Address - Street 2:STE 148
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-3676
Practice Address - Country:US
Practice Address - Phone:909-981-5882
Practice Address - Fax:909-946-0833
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8116207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX81160Medicaid
CA020A81160Medicare ID - Type Unspecified
CA00AX81160Medicaid