Provider Demographics
NPI:1205996048
Name:PHAM, AN T (MD)
Entity type:Individual
Prefix:
First Name:AN
Middle Name:T
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 1:600 INTERNATIONAL BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94606-2993
Mailing Address - Country:US
Mailing Address - Phone:510-208-3540
Mailing Address - Fax:510-208-3553
Practice Address - Street 1:600 INTERNATIONAL BLVD STE 102
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94606-2993
Practice Address - Country:US
Practice Address - Phone:510-208-3540
Practice Address - Fax:510-208-3553
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67904208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A679040Medicaid
CAH42075Medicare UPIN
CA00A679040Medicaid