=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275643793
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DUCTHANH N VU MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2202 STATE AVE SUITE 303 B
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32405-7601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-770-8120
-----------------------------------------------------
Fax | 850-770-8137
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 403631
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30384-3631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-740-0895
-----------------------------------------------------
Fax | 770-740-0896
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 96633
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------