Provider Demographics
NPI:1952628802
Name:PHAM, TRI (MD)
Entity Type:Individual
Prefix:
First Name:TRI
Middle Name:
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:PO BOX 1684
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71165-1684
Mailing Address - Country:US
Mailing Address - Phone:480-923-4675
Mailing Address - Fax:866-276-8064
Practice Address - Street 1:133 CHARLES AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-3719
Practice Address - Country:US
Practice Address - Phone:318-617-6708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-30
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ9881207Q00000X
LA206191208100000X
LAMD206191207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation