Provider Demographics
NPI:1124207006
Name:PHAN, ANTHONY THONG (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:THONG
Last Name:PHAN
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 1:1189 SWALLOW LN STE 110
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-3157
Mailing Address - Country:US
Mailing Address - Phone:805-526-3213
Mailing Address - Fax:805-583-5929
Practice Address - Street 1:1189 SWALLOW LN STE 110
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-3157
Practice Address - Country:US
Practice Address - Phone:805-526-3213
Practice Address - Fax:805-583-5929
Is Sole Proprietor?:No
Enumeration Date:2007-10-29
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG83470207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G834700OtherMEDICAL PROVIDER NUMBER
CAO5D0989497OtherCLIA
CAG16388Medicare UPIN
CA00G834700OtherMEDICAL PROVIDER NUMBER
CAO5D0989497OtherCLIA