Provider Demographics
NPI:1477623635
Name:PHAM, KEVIN (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:PHAM
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 1:500 S MAIN ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4507
Mailing Address - Country:US
Mailing Address - Phone:714-836-4204
Mailing Address - Fax:714-836-1809
Practice Address - Street 1:500 S MAIN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4507
Practice Address - Country:US
Practice Address - Phone:714-836-4204
Practice Address - Fax:714-836-1809
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67209207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
00A672090OtherCALOPTIMA
00A672090OtherBLUE SHIELD
CAH14188Medicare UPIN
W17376Medicare PIN
00A672090OtherBLUE SHIELD