Provider Demographics
NPI:1093767683
Name:PHAM, THAO PHUONG (DO)
Entity Type:Individual
Prefix:DR
First Name:THAO
Middle Name:PHUONG
Last Name:PHAM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:THAO
Other - Middle Name:P
Other - Last Name:PHAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:15717 15 MILE RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-2101
Mailing Address - Country:US
Mailing Address - Phone:586-285-3800
Mailing Address - Fax:586-285-3818
Practice Address - Street 1:15717 15 MILE RD
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48035-2101
Practice Address - Country:US
Practice Address - Phone:586-285-3800
Practice Address - Fax:586-285-3818
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014259207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1022812OtherMHP HAN INDIVIDUAL
MI4474588Medicaid
MI4963661Medicaid
MI700E012740OtherBCBS GROUP NUMBER
MI1022851OtherMHP HAN GROUP
MI080D410020OtherBCBS BCN COMM BLUE
MI4474579Medicaid
MI4474597Medicaid
MI080D410020OtherBCBS BCN COMM BLUE
MI0E06239077Medicare ID - Type Unspecified
MI4474597Medicaid