Provider Demographics
NPI:1255710745
Name:PHAM, CHARLOTTE (DO)
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:
Last Name:PHAM
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 1:1501 WHITE PINE DRIVE
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NY
Mailing Address - Zip Code:24405-2896
Mailing Address - Country:US
Mailing Address - Phone:917-853-5977
Mailing Address - Fax:
Practice Address - Street 1:508 FULTON ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-3875
Practice Address - Country:US
Practice Address - Phone:919-286-0411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-29
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102206601208100000X
CT63665208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation