Basic Information
| Provider Information | |||||||||
| NPI: | 1811980394 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUONG | ||||||||
| FirstName: | JIM | ||||||||
| MiddleName: | PHUOC | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 411 LAUREL ST | ||||||||
| Address2: | STE 3170 | ||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503143017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152830463 | ||||||||
| FaxNumber: | 5152830794 | ||||||||
| Practice Location | |||||||||
| Address1: | 411 LAUREL ST | ||||||||
| Address2: | STE 3170 | ||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503143017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152830463 | ||||||||
| FaxNumber: | 5152830794 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2005 | ||||||||
| LastUpdateDate: | 09/28/2007 | ||||||||
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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 | 207L00000X | 35166 | IA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 0295287 | 05 | IA | MEDICAID |