Healthcare Provider Details

I. General information

NPI: 1093874232
Provider Name (Legal Business Name): KHUONG VUONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 12/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 JACKSON ST MAIL CODE 11107E
SAINT PAUL MN
55101-2502
US

IV. Provider business mailing address

640 JACKSON ST MAIL CODE 11107E
SAINT PAUL MN
55101-2502
US

V. Phone/Fax

Practice location:
  • Phone: 651-254-9545
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number102815
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: