Provider Demographics
NPI:1568877264
Name:PHAM, PETER DUY (DPM)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:DUY
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 1:9900 SW HALL BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-5838
Mailing Address - Country:US
Mailing Address - Phone:503-245-2420
Mailing Address - Fax:503-245-2445
Practice Address - Street 1:17200 NW CORRIDOR CT STE 108
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-3295
Practice Address - Country:US
Practice Address - Phone:503-292-9252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-23
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT52-2014213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist