Provider Demographics
NPI:1376617357
Name:PHAM, HIEP QUANG (MD)
Entity Type:Individual
Prefix:MR
First Name:HIEP
Middle Name:QUANG
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 1:639 N MILLS AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803
Mailing Address - Country:US
Mailing Address - Phone:407-897-3260
Mailing Address - Fax:407-897-1112
Practice Address - Street 1:639 N MILLS AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803
Practice Address - Country:US
Practice Address - Phone:407-897-3260
Practice Address - Fax:407-897-1112
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME045427208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL044120100Medicaid
D50408Medicare UPIN
FL044120100Medicaid