Provider Demographics
NPI:1568500411
Name:PHAM, LESLIE (MD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:
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 1:18356 SANTA JOANANA
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-5620
Mailing Address - Country:US
Mailing Address - Phone:714-875-3842
Mailing Address - Fax:
Practice Address - Street 1:101 LAGUNA RD STE C
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-3637
Practice Address - Country:US
Practice Address - Phone:714-888-2080
Practice Address - Fax:714-888-2099
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2020-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD13906207W00000X
CAA117423207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIU400247722Medicare PIN
RI003252101Medicare PIN