Provider Demographics
NPI:1710925086
Name:PHAM, MINH THANH
Entity Type:Individual
Prefix:
First Name:MINH
Middle Name:THANH
Last Name:PHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:MICHAEL
Other - Middle Name:MINH
Other - Last Name:PHAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 662154
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91066-2154
Mailing Address - Country:US
Mailing Address - Phone:626-447-0296
Mailing Address - Fax:626-447-6057
Practice Address - Street 1:15107 VANOWEN ST
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-4542
Practice Address - Country:US
Practice Address - Phone:818-902-2990
Practice Address - Fax:818-904-3793
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69661207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA050126CH18382OtherVALLEY PRES TRAILBLAZER
CAA69661OtherBLUE CROSS
CA00A696610OtherCALOPTIMA
CA00A696610Medicaid
CA00A696610OtherBLUE SHIELD
CA00A696610OtherBLUE SHIELD
CAWA69661FMedicare PIN
CA00A696610OtherCALOPTIMA
CAA69661OtherBLUE CROSS
CA00A696610Medicaid