Provider Demographics
NPI:1467445403
Name:PHAM, BAO TIEN (DO)
Entity Type:Individual
Prefix:DR
First Name:BAO
Middle Name:TIEN
Last Name:PHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:5377 COMMISSIONERS DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-0830
Mailing Address - Country:US
Mailing Address - Phone:904-527-3135
Mailing Address - Fax:904-683-4293
Practice Address - Street 1:6816 SOUTHPOINT PKWY
Practice Address - Street 2:SUITE 302
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-1700
Practice Address - Country:US
Practice Address - Phone:904-527-3135
Practice Address - Fax:904-683-4293
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS72962081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL57410CMedicare ID - Type UnspecifiedMEDICARE #
FLF81361Medicare UPIN