Provider Demographics
NPI:1003917055
Name:PHAM, MATT HAI (MD)
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:HAI
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 1:500 N RAINBOW BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107-1082
Mailing Address - Country:US
Mailing Address - Phone:702-450-1717
Mailing Address - Fax:702-947-6740
Practice Address - Street 1:500 N RAINBOW BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89107-1082
Practice Address - Country:US
Practice Address - Phone:702-450-1717
Practice Address - Fax:702-947-6740
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11052207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100505793Medicaid
NV100948Medicare ID - Type Unspecified
NVI35164Medicare UPIN
NV100505793Medicaid