Healthcare Provider Details

I. General information

NPI: 1104957190
Provider Name (Legal Business Name): JACOB LY DUONG D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 05/18/2022
Certification Date: 05/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BREWSTER BLVD
CAMP LEJEUNE NC
28547-2575
US

IV. Provider business mailing address

100 BREWSTER BLVD
CAMP LEJEUNE NC
28547-2575
US

V. Phone/Fax

Practice location:
  • Phone: 910-449-6126
  • Fax:
Mailing address:
  • Phone: 910-449-6126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License NumberOS 11893
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS 11893
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License NumberOS11893
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: