Basic Information
| Provider Information | |||||||||
| NPI: | 1356620157 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FLANAGAN | ||||||||
| FirstName: | PHUONG | ||||||||
| MiddleName: | MY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3434 HANCOCK BRIDGE PKWY STE 301 | ||||||||
| Address2: | |||||||||
| City: | NORTH FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339037099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778563774 | ||||||||
| FaxNumber: | 2395992612 | ||||||||
| Practice Location | |||||||||
| Address1: | 2351 AARON ST | ||||||||
| Address2: | |||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339525305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8559795700 | ||||||||
| FaxNumber: | 8559795701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2011 | ||||||||
| LastUpdateDate: | 08/21/2019 | ||||||||
| 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 | 207R00000X | ME120139 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | ME120139 | FL | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 013411200 | 05 | FL | MEDICAID | 14XW1 | 01 | FL | BCBSFL | OTHER |