Provider Demographics
NPI:1477659001
Name:PHAM, TRI MINH (MD)
Entity Type:Individual
Prefix:DR
First Name:TRI
Middle Name:MINH
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 1:1130 COFFEE ROAD
Mailing Address - Street 2:SUITE 2-A
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355
Mailing Address - Country:US
Mailing Address - Phone:209-527-1870
Mailing Address - Fax:209-527-4548
Practice Address - Street 1:1130 COFFEE ROAD
Practice Address - Street 2:SUITE 2-A
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355
Practice Address - Country:US
Practice Address - Phone:209-527-1870
Practice Address - Fax:209-527-4548
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA35619207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A35619Medicaid
CO3944Medicare UPIN
00A35619Medicare ID - Type Unspecified