Provider Demographics
NPI:1417311374
Name:PHAN, MICHELLE QUYNH DAO (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:QUYNH DAO
Last Name:PHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3048 N WILTON AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-6710
Mailing Address - Country:US
Mailing Address - Phone:773-506-4283
Mailing Address - Fax:773-506-4847
Practice Address - Street 1:845 W WILSON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-8090
Practice Address - Country:US
Practice Address - Phone:773-506-4283
Practice Address - Fax:773-506-4847
Is Sole Proprietor?:No
Enumeration Date:2016-04-07
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD468228208000000X
CAA163063208000000X
OH35.136445208000000X
390200000X
IL036.150664208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036150664Medicaid