Provider Demographics
NPI:1942399548
Name:PHAN, PHILLIP C (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:C
Last Name:PHAN
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 1:5445 LA BRANCH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77004-6835
Mailing Address - Country:US
Mailing Address - Phone:713-973-7246
Mailing Address - Fax:832-553-1337
Practice Address - Street 1:5445 LA BRANCH ST STE 100
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77004-6835
Practice Address - Country:US
Practice Address - Phone:713-973-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN2242208VP0000X, 208VP0014X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX179470307Medicaid
TXI48625Medicare UPIN
TX8G3359Medicare PIN