Healthcare Provider Details

I. General information

NPI: 1881741668
Provider Name (Legal Business Name): KIEN TRI PHUNG D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 08/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

137 S ASPEN CT STE. C
VISALIA CA
93291-5175
US

IV. Provider business mailing address

100 E CALIFORNIA BLVD
PASADENA CA
91105-3205
US

V. Phone/Fax

Practice location:
  • Phone: 559-733-7024
  • Fax: 559-733-7169
Mailing address:
  • Phone: 626-568-8838
  • Fax: 626-574-7188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number20A13766
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: