Provider Demographics
NPI:1275626897
Name:PHAM, RANDAL TANH (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDAL
Middle Name:TANH
Last Name:PHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 OCONNOR DR
Mailing Address - Street 2:SUITE 180B
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-1633
Mailing Address - Country:US
Mailing Address - Phone:408-998-1818
Mailing Address - Fax:408-998-1884
Practice Address - Street 1:455 OCONNOR DR
Practice Address - Street 2:SUITE 180B
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1633
Practice Address - Country:US
Practice Address - Phone:408-998-1818
Practice Address - Fax:408-998-1884
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAGO71297174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF58293Medicare UPIN
CA00G12971Medicare ID - Type Unspecified
CA00G712970Medicare ID - Type Unspecified