Provider Demographics
NPI:1972869311
Name:PHAN, DIANA T (MD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:T
Last Name:PHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 LEE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92620-6202
Mailing Address - Country:US
Mailing Address - Phone:312-515-8056
Mailing Address - Fax:
Practice Address - Street 1:1740 W TAYLOR ST
Practice Address - Street 2:3200W UIH M/C515
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7232
Practice Address - Country:US
Practice Address - Phone:312-996-4021
Practice Address - Fax:312-996-4019
Is Sole Proprietor?:No
Enumeration Date:2012-04-10
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA129197207L00000X
IL036140455207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology