Provider Demographics
NPI:1558362723
Name:PHAM, THUY DICH (DO)
Entity Type:Individual
Prefix:
First Name:THUY
Middle Name:DICH
Last Name:PHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 70027
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92513-0027
Mailing Address - Country:US
Mailing Address - Phone:951-523-1117
Mailing Address - Fax:951-475-7013
Practice Address - Street 1:1530 W 6TH ST STE 109
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-2784
Practice Address - Country:US
Practice Address - Phone:855-505-7457
Practice Address - Fax:888-975-8926
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7794207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA020A77940OtherGROUP PRACTICE
CA1912919804OtherTYPE 2 NPI
CA00AX77940Medicaid
CA00AX77940Medicaid
CA1912919804OtherTYPE 2 NPI
CACB203096Medicare PIN
CA020A77940OtherGROUP PRACTICE