Provider Demographics
NPI:1790776995
Name:PHAM, THOMAS S (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:S
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 1:2489 DIPLOMAT PKWY E
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33909-5422
Mailing Address - Country:US
Mailing Address - Phone:239-652-1800
Mailing Address - Fax:248-655-0372
Practice Address - Street 1:2489 DIPLOMAT PKWY E
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33909-5422
Practice Address - Country:US
Practice Address - Phone:239-652-1800
Practice Address - Fax:248-655-0372
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-04
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301069802207N00000X
FLME118627207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H10943Medicare UPIN
FLHU092ZMedicare PIN
MI4318761Medicaid