Basic Information
| Provider Information | |||||||||
| NPI: | 1689757197 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUI | ||||||||
| FirstName: | CORY KHOIQUOC | ||||||||
| MiddleName: | TUONG | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BUI | ||||||||
| OtherFirstName: | KHOIQUOC | ||||||||
| OtherMiddleName: | TUONG | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11511 SHADOW CREEK PKWY | ||||||||
| Address2: | |||||||||
| City: | PEARLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775847298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134420000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 25553 US HIGHWAY 59 | ||||||||
| Address2: | |||||||||
| City: | PORTER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773655500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134422100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2006 | ||||||||
| LastUpdateDate: | 06/04/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | M5076 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 304534605 | 05 | TX | MEDICAID | 304534606 | 05 | TX | MEDICAID |