=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558661918
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHU SHENG PHUNG OD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2010
-----------------------------------------------------
Last Update Date | 08/26/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 315 S CENTER ST
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61701-5101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-827-2337
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2670 DEKALB AVE
-----------------------------------------------------
City | SYCAMORE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60178-3110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-895-3937
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 046.010355
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------