Provider Demographics
NPI:1659444081
Name:PHAN, NGHIA JOHN (DC)
Entity Type:Individual
Prefix:DR
First Name:NGHIA
Middle Name:JOHN
Last Name:PHAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 ESTUDILLO AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-4915
Mailing Address - Country:US
Mailing Address - Phone:510-483-2836
Mailing Address - Fax:510-483-3189
Practice Address - Street 1:433 ESTUDILLO AVE STE 100
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-4915
Practice Address - Country:US
Practice Address - Phone:510-483-2836
Practice Address - Fax:510-483-3189
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC27279111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0272790Medicaid
CADC0272790Medicaid