Provider Demographics
NPI:1346246998
Name:PHAN, NGOC AN (MD)
Entity Type:Individual
Prefix:DR
First Name:NGOC AN
Middle Name:
Last Name:PHAN
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 1:909 S 11TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-3701
Mailing Address - Country:US
Mailing Address - Phone:215-923-6080
Mailing Address - Fax:
Practice Address - Street 1:909 S 11TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19147-3701
Practice Address - Country:US
Practice Address - Phone:215-923-6080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2012-01-12
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
PAMD039037L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0090017101Medicaid
PA428533Medicare ID - Type Unspecified
PA0090017101Medicaid