Provider Demographics
NPI:1083226708
Name:PHAM, NICOLAS THONG (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLAS
Middle Name:THONG
Last Name:PHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:115 LEE BYRD RD
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-2310
Mailing Address - Country:US
Mailing Address - Phone:770-554-4717
Mailing Address - Fax:770-554-4681
Practice Address - Street 1:115 LEE BYRD RD
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-2310
Practice Address - Country:US
Practice Address - Phone:770-554-4717
Practice Address - Fax:770-554-4681
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA97811207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine