Provider Demographics
NPI:1235245895
Name:PHAN, LINDA K (MD)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:K
Last Name:PHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:252 MATLOCK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-4294
Mailing Address - Country:US
Mailing Address - Phone:817-557-5473
Mailing Address - Fax:817-539-0476
Practice Address - Street 1:252 MATLOCK RD STE 300
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-4294
Practice Address - Country:US
Practice Address - Phone:817-557-5473
Practice Address - Fax:817-539-0476
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTEMPLP208000000X
TXM4914208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX184093605Medicaid
1669442042OtherGRP NPI NUMBER