Provider Demographics
NPI:1578583597
Name:PHANUCHARAS, JIM PEDRAM (MD)
Entity Type:Individual
Prefix:DR
First Name:JIM
Middle Name:PEDRAM
Last Name:PHANUCHARAS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:7797 N 1ST ST # 270
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-0962
Mailing Address - Country:US
Mailing Address - Phone:559-261-2566
Mailing Address - Fax:559-435-4319
Practice Address - Street 1:7797 N 1ST ST # 270
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-0962
Practice Address - Country:US
Practice Address - Phone:559-261-2566
Practice Address - Fax:559-435-4319
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2015-12-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA82493207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A82493OtherCALIFORNIA LICENSE
A82493OtherCALIFORNIA LICENSE
CAI23752Medicare UPIN