Provider Demographics
NPI:1922005602
Name:HUYNH, PHUC TUAN (DO)
Entity Type:Individual
Prefix:
First Name:PHUC
Middle Name:TUAN
Last Name:HUYNH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2619 S WATERMAN AVE STE B
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3737
Mailing Address - Country:US
Mailing Address - Phone:909-424-0943
Mailing Address - Fax:909-424-0972
Practice Address - Street 1:2619 S WATERMAN AVE STE B
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3737
Practice Address - Country:US
Practice Address - Phone:909-424-0943
Practice Address - Fax:909-424-0972
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7890207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX78900Medicaid
H51908Medicare UPIN
CA020A78904Medicare ID - Type Unspecified