Provider Demographics
NPI:1073967584
Name:PHAM, CONNIE (DO)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:PHAM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 S CLARK ST STE 900
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60603-4043
Mailing Address - Country:US
Mailing Address - Phone:512-988-5355
Mailing Address - Fax:
Practice Address - Street 1:5781 KYLE PKWY STE 100
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640-6744
Practice Address - Country:US
Practice Address - Phone:512-988-5355
Practice Address - Fax:512-323-0307
Is Sole Proprietor?:No
Enumeration Date:2016-04-20
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS1221207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P02284117OtherRR MEDICARE
TX400345101Medicaid
831947OtherMEDICARE