Provider Demographics
NPI:1629100912
Name:PHAM, MINH VAN (MD)
Entity Type:Individual
Prefix:MR
First Name:MINH
Middle Name:VAN
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 1:5401 RAINIER AVE S
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98118-2438
Mailing Address - Country:US
Mailing Address - Phone:206-722-6268
Mailing Address - Fax:206-725-5435
Practice Address - Street 1:5401 RAINIER AVE S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98118-2438
Practice Address - Country:US
Practice Address - Phone:206-722-6268
Practice Address - Fax:206-725-5435
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00021481207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1038181Medicaid
WA0085250OtherLABOR & INDUSTRY
WA8931213OtherL & I CRIME VICTIMS COMP.
WA000104155Medicare ID - Type Unspecified
WA0085250OtherLABOR & INDUSTRY