Provider Demographics
NPI:1114098886
Name:NGOC MINH PHAM MD & SUONG MY TUONG MD A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:NGOC MINH PHAM MD & SUONG MY TUONG MD A MEDICAL CORPORATION
Other - Org Name:NGOC MINH PHAM MD
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NGOC
Authorized Official - Middle Name:MINH
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-268-1747
Mailing Address - Street 1:2363 ULRIC ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-6447
Mailing Address - Country:US
Mailing Address - Phone:858-268-1747
Mailing Address - Fax:858-268-4172
Practice Address - Street 1:2363 ULRIC STREET
Practice Address - Street 2:SUITE B
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-6447
Practice Address - Country:US
Practice Address - Phone:858-268-1747
Practice Address - Fax:858-268-4172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34924207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A349240Medicaid
CA00A349240Medicaid
CAA349240Medicare ID - Type Unspecified