Provider Demographics
NPI:1477656395
Name:PHAN, DENISE AD (MD)
Entity type:Individual
Prefix:MRS
First Name:DENISE
Middle Name:AD
Last Name:PHAN
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Gender:F
Credentials:MD
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Mailing Address - Street 1:15243 VANOWEN ST
Mailing Address - Street 2:SUITE 406
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-3605
Mailing Address - Country:US
Mailing Address - Phone:818-780-2106
Mailing Address - Fax:818-780-4271
Practice Address - Street 1:15243 VANOWEN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-3605
Practice Address - Country:US
Practice Address - Phone:818-785-0300
Practice Address - Fax:818-989-0297
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-10-01
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Provider Licenses
StateLicense IDTaxonomies
CAG73973207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG73973BMedicare PIN
CAG17933Medicare UPIN