Provider Demographics
NPI:1841297041
Name:PHUONG, LOI K (MD)
Entity type:Individual
Prefix:
First Name:LOI
Middle Name:K
Last Name:PHUONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7956 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4140
Practice Address - Country:US
Practice Address - Phone:260-436-2416
Practice Address - Fax:260-436-6936
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01057259A207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4657102Medicaid
IN140008277OtherRR MEDICARE
IN200420740Medicaid
OH2382103Medicaid
ININ4866034OtherMEDICARE PTAN
G82766Medicare UPIN
MI4657102Medicaid
OH2382103Medicaid
IN5506830003Medicare NSC
OH4120643Medicare PIN
OH4120642Medicare PIN
IN200420740Medicaid