Provider Demographics
NPI:1184797912
Name:PHAM, TONY TRUONG (DO)
Entity type:Individual
Prefix:DR
First Name:TONY
Middle Name:TRUONG
Last Name:PHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:TRUONG
Other - Middle Name:VAN
Other - Last Name:PHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1275 ANTIOCH DRIVE
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-6632
Mailing Address - Country:US
Mailing Address - Phone:972-722-0845
Mailing Address - Fax:
Practice Address - Street 1:820 N ZANG BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208
Practice Address - Country:US
Practice Address - Phone:214-946-1515
Practice Address - Fax:214-946-1545
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9389207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H89118Medicare UPIN
8C9499Medicare ID - Type Unspecified