Provider Demographics
NPI:1669454237
Name:PHAM, PHU T (MD)
Entity Type:Individual
Prefix:DR
First Name:PHU
Middle Name:T
Last Name:PHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:5525 RESEARCH PARK DR
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-4873
Mailing Address - Country:US
Mailing Address - Phone:703-923-4644
Mailing Address - Fax:703-923-4625
Practice Address - Street 1:7440 SPRING VILLAGE DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150-4446
Practice Address - Country:US
Practice Address - Phone:703-923-4644
Practice Address - Fax:703-923-4625
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2015-05-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0101043884207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010284121Medicaid
VA507073Medicare PIN
VAE54141Medicare UPIN