Healthcare Provider Details

I. General information

NPI: 1154942282
Provider Name (Legal Business Name): KHANH PHUONG DO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2020
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3214 J D KETHLEY RD
SHAWNEE OK
74804-9625
US

IV. Provider business mailing address

3214 J D KETHLEY RD
SHAWNEE OK
74804
US

V. Phone/Fax

Practice location:
  • Phone: 405-395-5600
  • Fax: 405-395-0852
Mailing address:
  • Phone: 405-395-5600
  • Fax: 405-395-0852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number41464
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: