Basic Information
| Provider Information | |||||||||
| NPI: | 1326392648 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DO | ||||||||
| FirstName: | AN | ||||||||
| MiddleName: | DUY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 455 PHILIP BLVD STE 140 | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300468768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709623642 | ||||||||
| FaxNumber: | 7709623643 | ||||||||
| Practice Location | |||||||||
| Address1: | 455 PHILIP BLVD STE 140 | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300468768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709623642 | ||||||||
| FaxNumber: | 7709623642 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2012 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 68998 | GA | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2081P2900X | 068998 | GA | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 208VP0014X | 068998 | GA | N | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 208VP0000X | 068998 | GA | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 003137500A | 05 | GA | MEDICAID | 003137500B | 05 | GA | MEDICAID | 003137500D | 05 | GA | MEDICAID | 003137500G | 05 | GA | MEDICAID | 003137500F | 05 | GA | MEDICAID | 003137500C | 05 | GA | MEDICAID |