Provider Demographics
NPI:1417531369
Name:PHAM, WILLIE C JR
Entity Type:Individual
Prefix:MR
First Name:WILLIE
Middle Name:C
Last Name:PHAM
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4614 PROSPECT AVE STE 323
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44103-4377
Mailing Address - Country:US
Mailing Address - Phone:216-273-7233
Mailing Address - Fax:
Practice Address - Street 1:4614 PROSPECT AVE STE 323
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44103-4377
Practice Address - Country:US
Practice Address - Phone:216-273-7233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-07
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator