Provider Demographics
NPI:1467031971
Name:PHUNG, ANDREW
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:PHUNG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 CONGRESS ST STE 208
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-3027
Mailing Address - Country:US
Mailing Address - Phone:626-792-2166
Mailing Address - Fax:626-795-0740
Practice Address - Street 1:10 CONGRESS ST STE 208
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3027
Practice Address - Country:US
Practice Address - Phone:626-792-2166
Practice Address - Fax:626-795-0740
Is Sole Proprietor?:No
Enumeration Date:2021-04-03
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA20A22573207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program