Provider Demographics
NPI:1003808312
Name:PHAM, TRUC THANH (MD)
Entity Type:Individual
Prefix:DR
First Name:TRUC
Middle Name:THANH
Last Name:PHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3985 STEVE REYNOLDS BLVD
Mailing Address - Street 2:SUITE K 102
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093-3035
Mailing Address - Country:US
Mailing Address - Phone:678-367-0390
Mailing Address - Fax:678-245-3391
Practice Address - Street 1:3985 STEVE REYNOLDS BLVD
Practice Address - Street 2:SUITE K 102
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-3035
Practice Address - Country:US
Practice Address - Phone:678-367-0390
Practice Address - Fax:678-245-3391
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA049706207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA844204821AMedicaid
GA52070574-001OtherBLUE CROSS BLUE SHIELD ID
GA844204821BMedicaid
GAH98477Medicare UPIN
GA844204821BMedicaid