Healthcare Provider Details

I. General information

NPI: 1679570717
Provider Name (Legal Business Name): KHANH TUAN VU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 10/23/2020
Certification Date: 10/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

381 RUIN CREEK RD
HENDERSON NC
27536-2932
US

IV. Provider business mailing address

381 RUIN CREEK RD
HENDERSON NC
27536-2932
US

V. Phone/Fax

Practice location:
  • Phone: 252-430-0666
  • Fax: 252-430-7503
Mailing address:
  • Phone: 252-430-0666
  • Fax: 252-430-7503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number36447
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: