Provider Demographics
NPI:1598710600
Name:PHAM, LUYEN (DPM)
Entity Type:Individual
Prefix:
First Name:LUYEN
Middle Name:
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 1:18133 OLD TRAIL LN
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-6859
Mailing Address - Country:US
Mailing Address - Phone:415-794-9841
Mailing Address - Fax:
Practice Address - Street 1:81713 US HWY 11
Practice Address - Street 2:STE F
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201
Practice Address - Country:US
Practice Address - Phone:760-342-2493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4677213E00000X, 213EP1101X, 213ES0000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB235513Medicare PIN
CACB235514Medicare PIN
CAV09491Medicare UPIN
CACA216415Medicare PIN