Provider Demographics
NPI:1760643779
Name:PHAM, PHUONG MINH (MD)
Entity Type:Individual
Prefix:
First Name:PHUONG
Middle Name:MINH
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 1:41540 WINCHESTER RD STE B
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-4877
Mailing Address - Country:US
Mailing Address - Phone:951-699-9201
Mailing Address - Fax:
Practice Address - Street 1:41540 WINCHESTER RD STE B
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590
Practice Address - Country:US
Practice Address - Phone:951-699-9201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA126343208200000X
GA704052086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery