Provider Demographics
NPI:1336299593
Name:PHAM, LOC NGOC (MD)
Entity Type:Individual
Prefix:DR
First Name:LOC
Middle Name:NGOC
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 1:1601 LAKE HARBIN RD
Mailing Address - Street 2:
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260-1721
Mailing Address - Country:US
Mailing Address - Phone:770-960-4699
Mailing Address - Fax:678-422-9368
Practice Address - Street 1:1601 LAKE HARBIN RD
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-1721
Practice Address - Country:US
Practice Address - Phone:770-960-4699
Practice Address - Fax:678-422-9368
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029360174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist