Provider Demographics
NPI:1659558195
Name:CONNIE PHAM, M.D.,P.A.
Entity Type:Organization
Organization Name:CONNIE PHAM, M.D.,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:5128-863-5678
Mailing Address - Street 1:2118 SCENIC DR
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-7728
Mailing Address - Country:US
Mailing Address - Phone:512-863-5678
Mailing Address - Fax:
Practice Address - Street 1:2118 SCENIC DR
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-7728
Practice Address - Country:US
Practice Address - Phone:512-863-5678
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-28
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH8321207QA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF25237Medicare UPIN