Provider Demographics
NPI:1063478402
Name:PHAN, PHUONG-CHI (MD)
Entity Type:Individual
Prefix:
First Name:PHUONG-CHI
Middle Name:
Last Name:PHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14571 MAGNOLIA ST
Mailing Address - Street 2:SUITE 207
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-5574
Mailing Address - Country:US
Mailing Address - Phone:714-890-9241
Mailing Address - Fax:714-890-9541
Practice Address - Street 1:14571 MAGNOLIA ST
Practice Address - Street 2:SUITE 207
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-5574
Practice Address - Country:US
Practice Address - Phone:714-890-9241
Practice Address - Fax:714-890-9541
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG76835207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G768350Medicaid
CA00G768350Medicaid