Provider Demographics
NPI:1750443594
Name:PHEN, BOPHAL
Entity Type:Individual
Prefix:MR
First Name:BOPHAL
Middle Name:
Last Name:PHEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 E VIRGINIA ST STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-5865
Mailing Address - Country:US
Mailing Address - Phone:408-938-2137
Mailing Address - Fax:408-998-1535
Practice Address - Street 1:160 E VIRGINIA ST
Practice Address - Street 2:#280
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112
Practice Address - Country:US
Practice Address - Phone:408-287-6200
Practice Address - Fax:408-998-1535
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA294011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical