Provider Demographics
NPI:1306838511
Name:HOANG, PHAT DAI (MD)
Entity Type:Individual
Prefix:DR
First Name:PHAT
Middle Name:DAI
Last Name:HOANG
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:P.O. BOX 7310
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85011-7310
Mailing Address - Country:US
Mailing Address - Phone:623-536-6788
Mailing Address - Fax:623-536-9288
Practice Address - Street 1:13065 W MCDOWELL RD
Practice Address - Street 2:SUITE A105
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-6439
Practice Address - Country:US
Practice Address - Phone:623-536-6788
Practice Address - Fax:623-536-9288
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2011-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ23025207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ109444OtherMEDICARE LEGACY NUMBER
AZ332049Medicaid
AZZ109444OtherMEDICARE LEGACY NUMBER