Provider Demographics
NPI:1346292604
Name:PHUONG, MARY JENNIFER YAO ONG (MD)
Entity type:Individual
Prefix:DR
First Name:MARY JENNIFER
Middle Name:YAO ONG
Last Name:PHUONG
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:2121 LAKE AVE
Mailing Address - Street 2:OPERATING ROOM - THIRD FLOOR
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5100
Mailing Address - Country:US
Mailing Address - Phone:260-426-5431
Mailing Address - Fax:260-460-1383
Practice Address - Street 1:5734 COVENTRY LN
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-7141
Practice Address - Country:US
Practice Address - Phone:260-436-8775
Practice Address - Fax:260-432-9812
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01057246207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200445020Medicaid
IN145420NMedicare ID - Type Unspecified
IN200445020Medicaid