Provider Demographics
NPI:1669456000
Name:PHAM, LAC HONG (MD)
Entity Type:Individual
Prefix:DR
First Name:LAC
Middle Name:HONG
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 1:157 N LAKEMONT AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-3214
Mailing Address - Country:US
Mailing Address - Phone:407-644-6618
Mailing Address - Fax:407-644-3755
Practice Address - Street 1:157 N LAKEMONT AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-3214
Practice Address - Country:US
Practice Address - Phone:407-644-6618
Practice Address - Fax:407-644-3755
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 34155208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD55028Medicare UPIN