Provider Demographics
NPI:1952315319
Name:PHUNG, THANH G (MD)
Entity Type:Individual
Prefix:
First Name:THANH
Middle Name:G
Last Name:PHUNG
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 1:15027 SOUTH PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:LAWNDALE
Mailing Address - State:CA
Mailing Address - Zip Code:90260
Mailing Address - Country:US
Mailing Address - Phone:310-970-9040
Mailing Address - Fax:310-970-9201
Practice Address - Street 1:15027 SOUTH PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:LAWNDALE
Practice Address - State:CA
Practice Address - Zip Code:90260
Practice Address - Country:US
Practice Address - Phone:310-970-9040
Practice Address - Fax:310-970-9201
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC423482085R0202X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C423480Medicaid
CA00C423480Medicaid