Provider Demographics
NPI:1558380329
Name:PHAM, ROSALIE D (MD)
Entity Type:Individual
Prefix:
First Name:ROSALIE
Middle Name:D
Last Name:PHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11510 GEORGIA AVE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:WHEATON
Mailing Address - State:MD
Mailing Address - Zip Code:20902-1925
Mailing Address - Country:US
Mailing Address - Phone:301-946-5100
Mailing Address - Fax:301-929-0348
Practice Address - Street 1:110 IRVING ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010-2976
Practice Address - Country:US
Practice Address - Phone:301-946-5100
Practice Address - Fax:301-929-0348
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD31509207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC202426OtherKAISER
DC5025620OtherAETNA NON HMO
DC2495246OtherAETNA HMO
VA441050OtherANTHEM BCBS
VA5704863Medicaid
DC0104OtherCAREFIRST BCBS
DC493309OtherNCPPO
VA5704863Medicaid
DC00A275C13Medicare ID - Type UnspecifiedTRAILBLAZER MEDICARE