Provider Demographics
NPI:1407871015
Name:PHAM, TIMOTHY (DPM)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:PHAM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1879 LUNDY AVE # 122
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95131-1834
Mailing Address - Country:US
Mailing Address - Phone:408-433-3930
Mailing Address - Fax:408-433-3931
Practice Address - Street 1:1879 LUNDY AVE # 122
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95131-1834
Practice Address - Country:US
Practice Address - Phone:408-433-3930
Practice Address - Fax:408-433-3931
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2007-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA000E39370213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E39370Medicaid
CA000E39371Medicare PIN
CA5735050001Medicare NSC
CA000E39370Medicaid