Provider Demographics
NPI:1588641948
Name:PHAM, KELLY H (DO)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:H
Last Name:PHAM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:N/A
Other - Middle Name:
Other - Last Name:N/A
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:6600 BRUCEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-4671
Mailing Address - Country:US
Mailing Address - Phone:916-688-6187
Mailing Address - Fax:916-688-6126
Practice Address - Street 1:6600 BRUCEVILLE RD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-4671
Practice Address - Country:US
Practice Address - Phone:916-688-6187
Practice Address - Fax:916-688-6126
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A77932085N0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARES000Medicare UPIN