Provider Demographics
NPI:1093035610
Name:PHAN, MIMI (MD)
Entity Type:Individual
Prefix:DR
First Name:MIMI
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 1:11307 FM 1960 RD W
Mailing Address - Street 2:STE 100
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77065-3687
Mailing Address - Country:US
Mailing Address - Phone:713-798-5588
Mailing Address - Fax:
Practice Address - Street 1:3601 N MACGREGOR WAY
Practice Address - Street 2:QUENTIN MEASE
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77004-8004
Practice Address - Country:US
Practice Address - Phone:713-873-4667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-04
Last Update Date:2016-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10038072207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine