Provider Demographics
NPI:1558392159
Name:PHAM, CO DANG LONG (MD)
Entity Type:Individual
Prefix:DR
First Name:CO
Middle Name:DANG LONG
Last Name:PHAM
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:10362 BOLSA AVE
Mailing Address - Street 2:BOLSA MEDICAL GROUP
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-6763
Mailing Address - Country:US
Mailing Address - Phone:714-531-2091
Mailing Address - Fax:714-531-1403
Practice Address - Street 1:10362 BOLSA AVE
Practice Address - Street 2:BOLSA MEDICAL GROUP
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-6763
Practice Address - Country:US
Practice Address - Phone:714-531-2091
Practice Address - Fax:714-531-1403
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2011-12-12
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Provider Licenses
StateLicense IDTaxonomies
CAA34091207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A340910Medicaid
CA00A340910Medicaid
C03927Medicare UPIN