Provider Demographics
NPI:1972879427
Name:PHAM, KHOA DANG
Entity Type:Individual
Prefix:
First Name:KHOA
Middle Name:DANG
Last Name:PHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 HORSEBACK
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92602-1817
Mailing Address - Country:US
Mailing Address - Phone:949-973-1061
Mailing Address - Fax:
Practice Address - Street 1:8860 BOLSA AVE
Practice Address - Street 2:STE B2
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-5499
Practice Address - Country:US
Practice Address - Phone:714-373-8555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-29
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA142496207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology