Provider Demographics
NPI:1386818482
Name:PHAM, LARRY D (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:D
Last Name:PHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1 HOAG DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-4162
Mailing Address - Country:US
Mailing Address - Phone:949-764-4624
Mailing Address - Fax:405-751-3183
Practice Address - Street 1:1 HOAG DR
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-4162
Practice Address - Country:US
Practice Address - Phone:949-764-4624
Practice Address - Fax:405-751-3183
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-18
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA101563207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1386181482Medicaid
CA1386181482Medicaid