Basic Information
Provider Information | |||||||||
NPI: | 1124041942 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DOAN | ||||||||
FirstName: | MINH-PHUONG | ||||||||
MiddleName: | LU | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2101 E JEFFERSON ST | ||||||||
Address2: | KAISER PERMANENTE MEDICARE ENROLLMENT | ||||||||
City: | ROCKVILLE | ||||||||
State: | MD | ||||||||
PostalCode: | 208524908 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3018162424 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 12255 FAIR LAKES PKWY | ||||||||
Address2: | KAISER PERMANENTE | ||||||||
City: | FAIRFAX | ||||||||
State: | VA | ||||||||
PostalCode: | 220333952 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7029345700 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/25/2006 | ||||||||
LastUpdateDate: | 06/07/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/07/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | MD34002 | DC | N |   | Allopathic & Osteopathic Physicians | Ophthalmology |   | 207W00000X | D0064828 | MD | N |   | Allopathic & Osteopathic Physicians | Ophthalmology |   | 207W00000X | A90807 | CA | N |   | Allopathic & Osteopathic Physicians | Ophthalmology |   | 207W00000X | 0101240225 | VA | Y |   | Allopathic & Osteopathic Physicians | Ophthalmology |   |
ID Information
ID | Type | State | Issuer | Description | 00A908070 | 01 | CA | MEDI CAL | OTHER |