Provider Demographics
NPI:1093452112
Name:PHAM, ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:PHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:646 S RUE MARCEL
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:LA
Mailing Address - Zip Code:70056-8203
Mailing Address - Country:US
Mailing Address - Phone:504-289-5784
Mailing Address - Fax:
Practice Address - Street 1:1500 S FAIRFIELD AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1782
Practice Address - Country:US
Practice Address - Phone:773-257-5914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-19
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL125.079423207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program