Provider Demographics
NPI:1376571216
Name:PETER LAM THOAI PHUC, MD, INC.
Entity Type:Organization
Organization Name:PETER LAM THOAI PHUC, MD, INC.
Other - Org Name:GREATER POMONA MEDICAL & REHAB CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER (PHUC)
Authorized Official - Middle Name:THOAI
Authorized Official - Last Name:LAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-209-8319
Mailing Address - Street 1:2728 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-2512
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1184 E HOLT AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-5833
Practice Address - Country:US
Practice Address - Phone:909-865-1946
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT10558152WL0500X
CAA88219207QG0300X
CAPT28250225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Multi-Specialty
Not Answered207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAY53026Medicare UPIN
CAW19708Medicare ID - Type Unspecified