Provider Demographics
NPI:1619113503
Name:PHAN, THAO MINH (MD)
Entity Type:Individual
Prefix:
First Name:THAO
Middle Name:MINH
Last Name:PHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:THAO
Other - Middle Name:MINH
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1170 BAKER ST STE H1
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-4165
Mailing Address - Country:US
Mailing Address - Phone:949-791-3250
Mailing Address - Fax:949-791-3251
Practice Address - Street 1:1170 BAKER ST STE H1
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626
Practice Address - Country:US
Practice Address - Phone:949-791-3250
Practice Address - Fax:949-791-3251
Is Sole Proprietor?:No
Enumeration Date:2008-12-23
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA101844207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00942853OtherMEDICARE RAILROAD
CACH607ZMedicare PIN