Provider Demographics
NPI:1821040866
Name:PHAM, JUSTIN HUNG (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:HUNG
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 1:7026 OLD KATY RD STE 276
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77024-2187
Mailing Address - Country:US
Mailing Address - Phone:713-621-7436
Mailing Address - Fax:
Practice Address - Street 1:1520 E SAN PEDRO ST STE 102
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-5479
Practice Address - Country:US
Practice Address - Phone:956-704-5153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD165752085R0202X
TXP30592085R0202X
NMMD2007-02392085R0202X
CAA721162085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A711260Medicaid
PA102062266 0001Medicaid
KY7100056140Medicaid
00A711260OtherBLUE SHIELD
OH2927677Medicaid
PA102062266 0005Medicaid
CAWA71126VMedicare PIN
CABG681ZMedicare PIN
PA102062266 0001Medicaid
OH2927677Medicaid