Provider Demographics
NPI:1336321231
Name:VICTOR VAN PHAN, D.O., P.A.
Entity Type:Organization
Organization Name:VICTOR VAN PHAN, D.O., P.A.
Other - Org Name:PREMIER ORTHOPAEDICS AND SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:VAN
Authorized Official - Last Name:PHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:281-922-1800
Mailing Address - Street 1:11920 ASTORIA BLVD
Mailing Address - Street 2:SUITE 390
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77089-6097
Mailing Address - Country:US
Mailing Address - Phone:281-922-1800
Mailing Address - Fax:832-448-3716
Practice Address - Street 1:11920 ASTORIA BLVD
Practice Address - Street 2:SUITE 390
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77089-6097
Practice Address - Country:US
Practice Address - Phone:281-922-1800
Practice Address - Fax:832-448-3716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL3782207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX117031501Medicaid
5555760001Medicare NSC
00515ZMedicare PIN
TX117031501Medicaid