Provider Demographics
NPI:1932472669
Name:PHANTHAVADY, THONGPHANH (MD)
Entity Type:Individual
Prefix:
First Name:THONGPHANH
Middle Name:
Last Name:PHANTHAVADY
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 1:8946 LA RIVIERA DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95826-2160
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7500 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-5403
Practice Address - Country:US
Practice Address - Phone:916-681-1900
Practice Address - Fax:916-688-0225
Is Sole Proprietor?:No
Enumeration Date:2012-02-10
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA118769207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine