Provider Demographics
NPI:1033119540
Name:PHAN, KHUONG DINH (DO)
Entity Type:Individual
Prefix:DR
First Name:KHUONG
Middle Name:DINH
Last Name:PHAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8553 N BEACH ST
Mailing Address - Street 2:PMB 296
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-4919
Mailing Address - Country:US
Mailing Address - Phone:817-473-7197
Mailing Address - Fax:817-473-7198
Practice Address - Street 1:920 HIGHWAY 287 N
Practice Address - Street 2:SUITE 308
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-2627
Practice Address - Country:US
Practice Address - Phone:817-473-7197
Practice Address - Fax:817-473-7198
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7520207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00434893OtherMEDICARE RAILROAD PTAN
8X9320OtherBCBS PIN
DG4235OtherMEDICARE RAILROAD GROUP
TX180563202Medicaid
P00434893OtherMEDICARE RAILROAD PTAN
8F5952Medicare PIN