Provider Demographics
NPI:1548356470
Name:TRUONG, PHUONGTHAO MINH (OD)
Entity type:Individual
Prefix:
First Name:PHUONGTHAO
Middle Name:MINH
Last Name:TRUONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:THAO
Other - Middle Name:M
Other - Last Name:TRUONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:5725 BOULDER BLUFF DR
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-3828
Mailing Address - Country:US
Mailing Address - Phone:678-571-4245
Mailing Address - Fax:
Practice Address - Street 1:5725 BOULDER BLUFF DR
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-3828
Practice Address - Country:US
Practice Address - Phone:678-571-4245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001883152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU92352Medicare UPIN