Provider Demographics
NPI:1700851052
Name:PHAM, TRUNG H (DO)
Entity Type:Individual
Prefix:
First Name:TRUNG
Middle Name:H
Last Name:PHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10016 S MINGO RD STE A
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-5789
Mailing Address - Country:US
Mailing Address - Phone:918-459-0583
Mailing Address - Fax:918-250-0120
Practice Address - Street 1:10016 S MINGO RD STE A
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-5789
Practice Address - Country:US
Practice Address - Phone:918-459-0583
Practice Address - Fax:918-250-0120
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-21
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3313207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100223040HMedicaid
G31474Medicare UPIN
OK248423810Medicare PIN