Provider Demographics
NPI:1497152078
Name:PHAM, NGUYEN (MD)
Entity Type:Individual
Prefix:
First Name:NGUYEN
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 1:6044 CEDAR GLEN DR
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-0408
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:350 S OAK AVE
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:CA
Practice Address - Zip Code:95361-3519
Practice Address - Country:US
Practice Address - Phone:209-848-7026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-26
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY289724207R00000X, 208M00000X
CAA155987208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist