Provider Demographics
NPI:1417019969
Name:PHAN, THANH HUU (MD)
Entity Type:Individual
Prefix:
First Name:THANH
Middle Name:HUU
Last Name:PHAN
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 1:4000 HIGHLAND RD
Mailing Address - Street 2:#110
Mailing Address - City:WATERFORD TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48328
Mailing Address - Country:US
Mailing Address - Phone:248-681-1025
Mailing Address - Fax:248-681-1533
Practice Address - Street 1:4000 HIGHLAND RD
Practice Address - Street 2:#110
Practice Address - City:WATERFORD TWP
Practice Address - State:MI
Practice Address - Zip Code:48328
Practice Address - Country:US
Practice Address - Phone:248-681-1025
Practice Address - Fax:248-681-1533
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI035554208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgery
Not Answered2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0631662Medicare ID - Type Unspecified
A73809Medicare UPIN