MEDICARE: THAO P PHUNG MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	A125932	CA
2	208M00000X	Hospitalist Physician	A125932	CA

General Provider Information

NPI Number	:	1699909622
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THAO P PHUNG MD

Provider Business Mailing Address
First Line	:	2913 EL CAMINO REAL STE 316
Second Line	:
City	:	TUSTIN
State	:	CA
Zip	:	92782-8909
Country	:	US
Telephone Number	:	949-229-1153
Fax Number	:	657-245-3168

Provider Business Practice Location Address
First Line	:	2913 EL CAMINO REAL STE 316
Second Line	:
City	:	TUSTIN
State	:	CA
Zip	:	92782-8909
Country	:	US
Telephone Number	:	949-229-1153
Fax Number	:	657-245-3168

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/05/2009
Last Update Date	:	04/04/2019

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