Provider Demographics
NPI:1922260389
Name:PHUC HUYNH, DO, CPC, INC.
Entity Type:Organization
Organization Name:PHUC HUYNH, DO, CPC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PHUC
Authorized Official - Middle Name:
Authorized Official - Last Name:HUYNH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:909-659-5657
Mailing Address - Street 1:2619 S WATERMAN AVE
Mailing Address - Street 2:B
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3737
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2619 S WATERMAN AVE
Practice Address - Street 2:B
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3737
Practice Address - Country:US
Practice Address - Phone:909-659-5657
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-27
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7890207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX78900Medicaid
CA020A78904OtherMEDICARE ID
CA00AX78900Medicaid