Provider Demographics
NPI:1376653287
Name:PHAM, NGOC MINH (MD)
Entity Type:Individual
Prefix:
First Name:NGOC
Middle Name:MINH
Last Name:PHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2363 ULRIC ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-6447
Mailing Address - Country:US
Mailing Address - Phone:858-268-1747
Mailing Address - Fax:858-268-4172
Practice Address - Street 1:2363 ULRIC ST
Practice Address - Street 2:SUITE B
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-6447
Practice Address - Country:US
Practice Address - Phone:858-268-1747
Practice Address - Fax:858-268-4172
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA34924207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A349340Medicaid
CAA349240Medicare ID - Type Unspecified
CA00A349340Medicaid