Provider Demographics
NPI:1558322024
Name:PHAM, HAU TRONG (DPM)
Entity Type:Individual
Prefix:
First Name:HAU
Middle Name:TRONG
Last Name:PHAM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 HARRISON AVE
Mailing Address - Street 2:DOB 503
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2371
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:732 HARRISON AVE
Practice Address - Street 2:PRESTON 5TH FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2309
Practice Address - Country:US
Practice Address - Phone:617-414-6840
Practice Address - Fax:617-414-6710
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2017-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2079213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA000540601OtherMEDICARE ID
MA110013009AMedicaid
MA000540601OtherMEDICARE ID