Provider Demographics
NPI:1891919270
Name:PHAM, CUONG C (MD)
Entity Type:Individual
Prefix:DR
First Name:CUONG
Middle Name:C
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 1:1104 N DOREEN ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-3820
Mailing Address - Country:US
Mailing Address - Phone:316-634-0491
Mailing Address - Fax:
Practice Address - Street 1:ONE WILLIAM KEY BLVD
Practice Address - Street 2:
Practice Address - City:FORT SUPPLY
Practice Address - State:OK
Practice Address - Zip Code:73841-0061
Practice Address - Country:US
Practice Address - Phone:580-766-2224
Practice Address - Fax:580-766-2030
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23839207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSF20061Medicare UPIN
KS29962Medicare ID - Type Unspecified