Provider Demographics
NPI:1215054416
Name:PHANCAO, JEAN-PIERRE (MD)
Entity type:Individual
Prefix:
First Name:JEAN-PIERRE
Middle Name:
Last Name:PHANCAO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JEAN-PIERRE
Other - Middle Name:
Other - Last Name:PHAN CAO PHAI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 6102
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94948-6102
Mailing Address - Country:US
Mailing Address - Phone:415-884-3404
Mailing Address - Fax:
Practice Address - Street 1:500 REDWOOD BLVD STE 300
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947-6921
Practice Address - Country:US
Practice Address - Phone:415-464-8081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA979382085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A979380Medicaid
NJ0185469Medicaid
CAP00480244OtherRAILROAD MEDICARE
CABU437MMedicare PIN
CABU437OMedicare PIN
CABU437KMedicare PIN
CABU437ZMedicare PIN
CA00A979380Medicaid
NJ0185469Medicaid
CABU437QMedicare PIN
CABU437LMedicare PIN
NE099984006Medicare PIN
CABU437SMedicare PIN
CABU437UMedicare PIN
CABU437RMedicare PIN
CABU437WMedicare PIN
COCOA100164Medicare PIN
COCOA100165Medicare PIN
CABU437PMedicare PIN
CABU437TMedicare PIN
CABU437VMedicare PIN
CABU437XMedicare PIN