Provider Demographics
NPI:1649217217
Name:PHAM, THI KIM LOAN (MD)
Entity Type:Individual
Prefix:
First Name:THI KIM
Middle Name:LOAN
Last Name:PHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79440 CORPORATE CENTER DR STE 117
Mailing Address - Street 2:STE 117
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-7244
Mailing Address - Country:US
Mailing Address - Phone:760-863-0138
Mailing Address - Fax:760-863-0471
Practice Address - Street 1:79440 CORPORATE CENTER DR STE 117
Practice Address - Street 2:STE 117
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-7244
Practice Address - Country:US
Practice Address - Phone:760-863-0138
Practice Address - Fax:760-863-0471
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA60749207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G35728Medicare UPIN
CA00A607490Medicare ID - Type Unspecified