Provider Demographics
NPI:1811195563
Name:PHAN, PETER MINH (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:MINH
Last Name:PHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9 GOLDENRAIN
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-2118
Mailing Address - Country:US
Mailing Address - Phone:949-716-0949
Mailing Address - Fax:949-716-1105
Practice Address - Street 1:9 GOLDENRAIN
Practice Address - Street 2:
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-2118
Practice Address - Country:US
Practice Address - Phone:949-716-0949
Practice Address - Fax:949-716-1105
Is Sole Proprietor?:No
Enumeration Date:2007-07-04
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2007018365207U00000X
CAA912992085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology