Provider Demographics
NPI:1043472640
Name:PHAN, PHILIP (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:
Last Name:PHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:PHU
Other - Middle Name:GIA
Other - Last Name:PHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:393 E WALNUT STREET
Mailing Address - Street 2:3RD FLOOR - PHRS
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91188-0001
Mailing Address - Country:US
Mailing Address - Phone:626-405-7914
Mailing Address - Fax:818-375-4069
Practice Address - Street 1:8120 WOODMAN AVENUE
Practice Address - Street 2:PANORAMA CITY MEDICAL CENTER
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402
Practice Address - Country:US
Practice Address - Phone:818-375-2809
Practice Address - Fax:818-375-4069
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-26
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4394362084P0800X
PAMT1922162084P0800X
CAA1184842084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry