Healthcare Provider Details

I. General information

NPI: 1902930811
Provider Name (Legal Business Name): KENNY KHOA VU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 04/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 WOLF CREEK BLVD SUITE 2
DOVER DE
19901-4969
US

IV. Provider business mailing address

111 WOLF CREEK BLVD SUITE 2
DOVER DE
19901-4969
US

V. Phone/Fax

Practice location:
  • Phone: 302-678-0510
  • Fax: 302-678-2864
Mailing address:
  • Phone: 302-678-0510
  • Fax: 302-678-2864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberC7-0003034
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101240716
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC1-0008350
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: