Healthcare Provider Details

I. General information

NPI: 1639558687
Provider Name (Legal Business Name): CATHERINE PHUONG-TU PERRAULT D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2015
Last Update Date: 08/04/2023
Certification Date: 08/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NMRTU IWAKUNI, MCAS IWAKUNI 1 MISUMI MACHI
IWAKUNI YAMAGUCHI
7400025
JP

IV. Provider business mailing address

PSC 561 BOX 1877
FPO AP
96310-0019
US

V. Phone/Fax

Practice location:
  • Phone: 315-255-8100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS14153
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: