Provider Demographics
NPI:1407173230
Name:PHAM, RYAN (DO)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:PHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 SW JOHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-5833
Mailing Address - Country:US
Mailing Address - Phone:817-766-7421
Mailing Address - Fax:817-447-8100
Practice Address - Street 1:621 SW JOHNSON AVE
Practice Address - Street 2:SUITE C
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-5833
Practice Address - Country:US
Practice Address - Phone:817-766-7421
Practice Address - Fax:817-447-8100
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-04
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP1128207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology