Provider Demographics
NPI:1124555735
Name:PHAM, JUSTIN
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:PHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 TROUSDALE DR
Mailing Address - Street 2:
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-4506
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1501 TROUSDALE DR
Practice Address - Street 2:
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-4506
Practice Address - Country:US
Practice Address - Phone:650-696-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-12
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA177454207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program