Provider Demographics
NPI:1003045709
Name:PHAM, VICTOR NGUYEN (MD)
Entity Type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:NGUYEN
Last Name:PHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3655 W ANTHEM WAY STE A109
Mailing Address - Street 2:
Mailing Address - City:ANTHEM
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-0430
Mailing Address - Country:US
Mailing Address - Phone:623-879-5288
Mailing Address - Fax:623-879-1563
Practice Address - Street 1:9205 SW BARNES RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6603
Practice Address - Country:US
Practice Address - Phone:503-216-2906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-02
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-057211207R00000X
ORMD157726207R00000X, 208M00000X
AZ58475208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ58475OtherAZ LICENSE
ORP01701362OtherRR MEDICARE - PH&S - OREGON (PMG)
OR500647926Medicaid