Provider Demographics
NPI:1770679508
Name:PHAM, MYCHELLE N (MD)
Entity Type:Individual
Prefix:
First Name:MYCHELLE
Middle Name:N
Last Name:PHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3835
Mailing Address - Country:US
Mailing Address - Phone:714-289-4511
Mailing Address - Fax:714-204-3212
Practice Address - Street 1:455 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3835
Practice Address - Country:US
Practice Address - Phone:714-532-8620
Practice Address - Fax:714-289-4072
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA81905208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A819050Medicaid
CAW16177OtherMEDICARE GRP
CAHW16177OtherMEDICARE GRP
CAHW16177OtherMEDICARE GRP