Basic Information
Provider Information | |||||||||
NPI: | 1114180999 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PHUNG | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | THUY HO | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 600 COFFEE RD | ||||||||
Address2: |   | ||||||||
City: | MODESTO | ||||||||
State: | CA | ||||||||
PostalCode: | 953554201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2095216097 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2545 W HAMMER LN | ||||||||
Address2: |   | ||||||||
City: | STOCKTON | ||||||||
State: | CA | ||||||||
PostalCode: | 952092839 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2099577050 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/02/2008 | ||||||||
LastUpdateDate: | 09/23/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | A107567 | CA | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   | 174400000X | A107567 | CA | N |   | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 68-0277719 | 01 | CA | GROUP TAX ID | OTHER | 00A1075670 | 05 | CA |   | MEDICAID | 1386636165 | 01 | CA | GROUP NPI | OTHER |