Provider Demographics
NPI:1609196989
Name:PHAM, PHUNG (MD)
Entity Type:Individual
Prefix:
First Name:PHUNG
Middle Name:
Last Name:PHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8087 N SAVANNAH CIR
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-3031
Mailing Address - Country:US
Mailing Address - Phone:954-326-2781
Mailing Address - Fax:
Practice Address - Street 1:130 S UNIVERSITY DR STE D
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-3347
Practice Address - Country:US
Practice Address - Phone:954-998-6359
Practice Address - Fax:954-756-9999
Is Sole Proprietor?:No
Enumeration Date:2010-06-09
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME118146207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015825700Medicaid