Provider Demographics
NPI:1295001592
Name:PHAN, KIM MINH (DO)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:MINH
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:PO BOX 2466
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92263-2466
Mailing Address - Country:US
Mailing Address - Phone:760-416-4800
Mailing Address - Fax:
Practice Address - Street 1:1180 N INDIAN CANYON DR STE E218
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-4885
Practice Address - Country:US
Practice Address - Phone:760-416-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-30
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH012123207R00000X
CA20A13018207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine