Provider Demographics
NPI:1447419601
Name:KIEU, PHONG NGUYEN (MD)
Entity type:Individual
Prefix:
First Name:PHONG
Middle Name:NGUYEN
Last Name:KIEU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:123 SUMMER ST STE 320S
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01608-1216
Mailing Address - Country:US
Mailing Address - Phone:508-964-5580
Mailing Address - Fax:508-368-3143
Practice Address - Street 1:123 SUMMER ST STE 320S
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1216
Practice Address - Country:US
Practice Address - Phone:508-964-5580
Practice Address - Fax:508-368-3143
Is Sole Proprietor?:No
Enumeration Date:2008-06-03
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA254817208100000X, 2081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation