Provider Demographics
NPI:1881741668
Name:PHUNG, KIEN TRI (DO)
Entity type:Individual
Prefix:
First Name:KIEN
Middle Name:TRI
Last Name:PHUNG
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:100 E CALIFORNIA BLVD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-3205
Mailing Address - Country:US
Mailing Address - Phone:626-568-8838
Mailing Address - Fax:626-574-7188
Practice Address - Street 1:137 S ASPEN CT
Practice Address - Street 2:STE. C
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-5175
Practice Address - Country:US
Practice Address - Phone:559-733-7024
Practice Address - Fax:559-733-7169
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2016-08-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CA20A13766207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1881741668Medicaid
CACA158474Medicare UPIN
CA1881741668Medicaid