Provider Demographics
NPI:1114180999
Name:PHUNG, JENNIFER THUY HO (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:THUY HO
Last Name:PHUNG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 COFFEE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4201
Mailing Address - Country:US
Mailing Address - Phone:209-521-6097
Mailing Address - Fax:
Practice Address - Street 1:2545 W HAMMER LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95209-2839
Practice Address - Country:US
Practice Address - Phone:209-957-7050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA107567207V00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA68-0277719OtherGROUP TAX ID
CA00A1075670Medicaid
CA1386636165OtherGROUP NPI
CAZZZ14503ZMedicare PIN