Provider Demographics
NPI:1164566568
Name:PHAM, PHUC HONG (MD)
Entity Type:Individual
Prefix:
First Name:PHUC
Middle Name:HONG
Last Name:PHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:HONG
Other - Middle Name:PHUC
Other - Last Name:PHAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1505 N EDGEMONT ST BSMT
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-5209
Mailing Address - Country:US
Mailing Address - Phone:323-783-8985
Mailing Address - Fax:
Practice Address - Street 1:1505 N EDGEMONT ST BSMT
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-5209
Practice Address - Country:US
Practice Address - Phone:323-783-8985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-18
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA1015892085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program