Provider Demographics
NPI:1245497148
Name:PHAN, LAN TUYET (DO)
Entity type:Individual
Prefix:DR
First Name:LAN
Middle Name:TUYET
Last Name:PHAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 W COCOA BEACH CSWY
Practice Address - Street 2:
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931
Practice Address - Country:US
Practice Address - Phone:321-868-5871
Practice Address - Fax:321-868-5852
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-19
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7637208M00000X
FLOS 7637207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL567240OtherFL MEDICARE
FLP01711663OtherFL RR MEDICARE
FL000828200Medicaid