Individual
LOI K PHUONG
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
7956 W JEFFERSON BLVD, FORT WAYNE, IN 46804-4140
(260) 436-2416
(260) 436-6936
Mailing address
250 N SHADELAND AVE, INDIANAPOLIS, IN 46219-4959
Taxonomy
Speciality
Code
Description
License number
State
207T00000X
Neurological Surgery Physician
Primary
01057259A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
140008277
RR MEDICARE
IN
05
—
200420740
—
IN
05
—
2382103
—
OH
05
—
4657102
—
MI
01
—
IN4866034
MEDICARE PTAN
IN
Enumeration date
07/01/2005
Last updated
01/04/2024
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