Provider Demographics
NPI:1578740775
Name:KEVIN PHAM, M.D., INC
Entity Type:Organization
Organization Name:KEVIN PHAM, M.D., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-836-4204
Mailing Address - Street 1:500 S MAIN ST STE 101
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4535
Mailing Address - Country:US
Mailing Address - Phone:714-836-4204
Mailing Address - Fax:714-836-1809
Practice Address - Street 1:500 S MAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4535
Practice Address - Country:US
Practice Address - Phone:714-836-4204
Practice Address - Fax:714-836-1809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-30
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67209207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A672090OtherMEDICAL
CAH14188Medicare UPIN
CAW17376Medicare PIN