Provider Demographics
NPI:1447394465
Name:DANG, PHONG DAO LAM (MD)
Entity Type:Individual
Prefix:
First Name:PHONG
Middle Name:DAO LAM
Last Name:DANG
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 1:100 E LEFEVRE RD
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:IL
Mailing Address - Zip Code:61081-1278
Mailing Address - Country:US
Mailing Address - Phone:815-625-0400
Mailing Address - Fax:815-625-6728
Practice Address - Street 1:100 E LEFEVRE RD
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:IL
Practice Address - Zip Code:61081-1278
Practice Address - Country:US
Practice Address - Phone:815-625-0400
Practice Address - Fax:815-625-6728
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.117094207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036117094Medicaid
P00405463OtherRAILROAD MEDICARE
K38960Medicare PIN