Provider Demographics
NPI:1790749653
Name:PHAM, DZUNG ANH (DO)
Entity Type:Individual
Prefix:
First Name:DZUNG
Middle Name:ANH
Last Name:PHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2940 NAU AVE
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92782-3377
Mailing Address - Country:US
Mailing Address - Phone:949-654-8455
Mailing Address - Fax:888-805-6665
Practice Address - Street 1:2940 NAU AVE
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92782-3377
Practice Address - Country:US
Practice Address - Phone:949-654-8455
Practice Address - Fax:888-805-6665
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-17
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6269207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF74892Medicare UPIN