Provider Demographics
NPI:1437352630
Name:PHAN, DUKE AN MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:DUKE
Middle Name:AN MICHAEL
Last Name:PHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DUKE
Other - Middle Name:A
Other - Last Name:PHAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:17220 NEWHOPE ST
Mailing Address - Street 2:SUITE 217
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-4272
Mailing Address - Country:US
Mailing Address - Phone:714-546-4367
Mailing Address - Fax:714-546-4361
Practice Address - Street 1:17220 NEWHOPE ST
Practice Address - Street 2:SUITE 217
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-4272
Practice Address - Country:US
Practice Address - Phone:714-546-4367
Practice Address - Fax:714-546-4361
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA511932084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A511930Medicaid
CA00A511930OtherBLUE SHIELD
CA00A511930OtherBLUE SHIELD
G31647Medicare UPIN
CA00A511930Medicaid