Provider Demographics
NPI:1164573812
Name:PHAM, DAVE QUANG (DPM)
Entity Type:Individual
Prefix:
First Name:DAVE
Middle Name:QUANG
Last Name:PHAM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2506 POCAHONTAS PL
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63144-2108
Mailing Address - Country:US
Mailing Address - Phone:314-963-1314
Mailing Address - Fax:314-968-0092
Practice Address - Street 1:2506 POCAHONTAS PL
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63144-2108
Practice Address - Country:US
Practice Address - Phone:314-963-1314
Practice Address - Fax:314-968-0092
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO754213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO21323Medicare ID - Type UnspecifiedPODIATRIST