Provider Demographics
NPI:1043567407
Name:PHAN, PHUNG DINH (DO)
Entity type:Individual
Prefix:DR
First Name:PHUNG
Middle Name:DINH
Last Name:PHAN
Suffix:
Gender:M
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:UNIT 28038 BLD 700
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09112
Mailing Address - Country:US
Mailing Address - Phone:314-590-3904
Mailing Address - Fax:
Practice Address - Street 1:1625 SHEPHERD RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33811-2122
Practice Address - Country:US
Practice Address - Phone:863-284-1626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-04
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1141171000000X, 207Q00000X
FLOS20770207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No171000000XOther Service ProvidersMilitary Health Care Provider