Provider Demographics
NPI:1710006556
Name:KHUONG PHAN, D.O., P.A.
Entity Type:Organization
Organization Name:KHUONG PHAN, D.O., P.A.
Other - Org Name:MANSFIELD MEDICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KHUONG
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:817-473-7197
Mailing Address - Street 1:920 HIGHWAY 287 N
Mailing Address - Street 2:STE. 308
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-2627
Mailing Address - Country:US
Mailing Address - Phone:817-473-7197
Mailing Address - Fax:817-473-7198
Practice Address - Street 1:920 HIGHWAY 287 N
Practice Address - Street 2:SUITE 308
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-2627
Practice Address - Country:US
Practice Address - Phone:817-473-7197
Practice Address - Fax:817-473-7197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7520207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX180563202Medicaid
I39935Medicare UPIN