Provider Demographics
NPI:1780693671
Name:DUONG, JACKY THUVAN (DO)
Entity type:Individual
Prefix:DR
First Name:JACKY
Middle Name:THUVAN
Last Name:DUONG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 S SAGINAW ST
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48502-1803
Mailing Address - Country:US
Mailing Address - Phone:810-232-3522
Mailing Address - Fax:810-762-4494
Practice Address - Street 1:420 S SAGINAW ST
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48502-1803
Practice Address - Country:US
Practice Address - Phone:810-232-3522
Practice Address - Fax:810-762-4494
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014969207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700B512440OtherBCBS GROUP
MI114632050Medicaid
MI114632687Medicaid
MION69170OtherMEDICARE GROUP
MI114632696Medicaid
MI114632041Medicaid
MI114632060Medicaid
MI700H248710OtherBLUE CROSS GROUP NUMBER
MI0M69920015Medicare ID - Type Unspecified
MI114632041Medicaid
MIN69170125Medicare PIN