Provider Demographics
NPI:1083787048
Name:PHAN, BAO LONG (MD)
Entity Type:Individual
Prefix:DR
First Name:BAO
Middle Name:LONG
Last Name:PHAN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:330 MUNICIPAL DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-3651
Mailing Address - Country:US
Mailing Address - Phone:972-671-6398
Mailing Address - Fax:972-235-6419
Practice Address - Street 1:330 MUNICIPAL DR
Practice Address - Street 2:SUITE 104
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-3651
Practice Address - Country:US
Practice Address - Phone:972-671-6398
Practice Address - Fax:972-235-6419
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXL4198208200000X
HI13456208200000X
CAA61602208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
H75255Medicare UPIN
8A1690Medicare ID - Type Unspecified