Provider Demographics
NPI:1790787802
Name:PHAM, CUNG BRYAN (MD)
Entity Type:Individual
Prefix:DR
First Name:CUNG
Middle Name:BRYAN
Last Name:PHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:CUNG
Other - Middle Name:BUI
Other - Last Name:PHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:517 SUSANA AVE
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-3953
Mailing Address - Country:US
Mailing Address - Phone:310-956-5409
Mailing Address - Fax:
Practice Address - Street 1:650 5TH ST STE 405
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94107-1541
Practice Address - Country:US
Practice Address - Phone:888-713-5540
Practice Address - Fax:415-231-5332
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA227004207Q00000X
CAA81143207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A811430Medicaid
CAI23011Medicare UPIN
CA00A811430Medicaid