Provider Demographics
NPI:1588861587
Name:DUONG, MYTO (MB, BCH, BAO)
Entity type:Individual
Prefix:DR
First Name:MYTO
Middle Name:
Last Name:DUONG
Suffix:
Gender:F
Credentials:MB, BCH, BAO
Other - Prefix:DR
Other - First Name:MYTO
Other - Middle Name:
Other - Last Name:DUONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MB, BCH, BAO
Mailing Address - Street 1:PO BOX 19638
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9638
Mailing Address - Country:US
Mailing Address - Phone:217-545-7409
Mailing Address - Fax:217-545-2711
Practice Address - Street 1:800 E CARPENTER ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62769-1000
Practice Address - Country:US
Practice Address - Phone:217-545-7409
Practice Address - Fax:217-545-2711
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005018588390200000X
IL036-121953207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036121953Medicaid
IL036121953Medicaid