Provider Demographics
NPI:1275835688
Name:T MAI PHAN MD INC
Entity Type:Organization
Organization Name:T MAI PHAN MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TUYET-MAI
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-775-4400
Mailing Address - Street 1:9500 BOLSA AVE
Mailing Address - Street 2:SUITE P
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-5943
Mailing Address - Country:US
Mailing Address - Phone:714-775-4400
Mailing Address - Fax:714-775-0149
Practice Address - Street 1:9500 BOLSA AVE
Practice Address - Street 2:SUITE P
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-5943
Practice Address - Country:US
Practice Address - Phone:714-775-4400
Practice Address - Fax:714-775-0149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-18
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G576702Medicaid
CA00G576701Medicaid
CA00G576702Medicaid
CA63883Medicare UPIN
CA00G576701Medicaid