Provider Demographics
NPI:1144754607
Name:PHAM, KEVIN K (DO)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:K
Last Name:PHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 E PEARL ST
Mailing Address - Street 2:
Mailing Address - City:JERSEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62052-1863
Mailing Address - Country:US
Mailing Address - Phone:714-261-0176
Mailing Address - Fax:
Practice Address - Street 1:414 S STATE ST
Practice Address - Street 2:
Practice Address - City:ROODHOUSE
Practice Address - State:IL
Practice Address - Zip Code:62082
Practice Address - Country:US
Practice Address - Phone:217-589-4383
Practice Address - Fax:217-589-4409
Is Sole Proprietor?:No
Enumeration Date:2017-04-11
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036157104207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL37-6013958OtherIRS