Provider Demographics
NPI:1326357856
Name:PHAM, BAO LAN DUC (MD)
Entity Type:Individual
Prefix:DR
First Name:BAO LAN
Middle Name:DUC
Last Name:PHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:712 N WASHINGTON AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1619
Mailing Address - Country:US
Mailing Address - Phone:214-826-8822
Mailing Address - Fax:
Practice Address - Street 1:712 N WASHINGTON AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1619
Practice Address - Country:US
Practice Address - Phone:214-826-8822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-01
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP62442085B0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging