Provider Demographics
NPI:1588674030
Name:PHAN, AN T (MD)
Entity Type:Individual
Prefix:DR
First Name:AN
Middle Name:T
Last Name:PHAN
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:1370 DORCHESTER AVE
Mailing Address - Street 2:STE 23
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02122-2921
Mailing Address - Country:US
Mailing Address - Phone:617-288-8883
Mailing Address - Fax:617-288-8887
Practice Address - Street 1:1370 DORCHESTER AVE
Practice Address - Street 2:STE 23
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122-2921
Practice Address - Country:US
Practice Address - Phone:617-288-8883
Practice Address - Fax:617-288-8887
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2016-11-30
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Provider Licenses
StateLicense IDTaxonomies
MA82073207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110057033AMedicaid
G59793Medicare UPIN
MAS300311384Medicare Oscar/Certification