Provider Demographics
NPI:1821016148
Name:PHAN, ALEXANDRIA T (MD)
Entity Type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:T
Last Name:PHAN
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 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-0505
Mailing Address - Fax:414-955-0231
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-0505
Practice Address - Fax:414-955-0231
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL3069207RX0202X, 207RH0003X, 207R00000X
WI23373-875207RH0003X, 207RX0202X
NMMD2016-0653207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8EE349OtherBLUE CROSS BLUE SHIELD
TX8J1932OtherBCBS
TX147345602Medicaid
TX1821016148OtherBLUE CROSS BLUE SHIELD
WI1821016148Medicaid
TXP01186458OtherRR MEDICARE
TX147345603Medicaid
TX8J1932OtherBCBS
TXH50978Medicare UPIN
TX147345603Medicaid