Healthcare Provider Details

I. General information

NPI: 1053561134
Provider Name (Legal Business Name): PHUC T PHUNG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2008
Last Update Date: 07/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24920 104TH AVE SE
KENT WA
98030-6443
US

IV. Provider business mailing address

PO BOX 34876
SEATTLE WA
98124-1876
US

V. Phone/Fax

Practice location:
  • Phone: 253-395-2000
  • Fax: 253-395-1946
Mailing address:
  • Phone: 425-656-5412
  • Fax: 425-656-4096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD60178745
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: