Provider Demographics
NPI:1922699271
Name:PHUNG, THI PHUONG THUY
Entity Type:Individual
Prefix:
First Name:THI PHUONG THUY
Middle Name:
Last Name:PHUNG
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 1:2969 MOJAVE DR
Mailing Address - Street 2:
Mailing Address - City:WEST SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95691-5187
Mailing Address - Country:US
Mailing Address - Phone:916-296-0982
Mailing Address - Fax:
Practice Address - Street 1:1689 ARDEN WAY STE 1091
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95815-4096
Practice Address - Country:US
Practice Address - Phone:916-929-5909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-29
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34765152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist