Provider Demographics
NPI:1649995937
Name:PHAM, HUAN PHU
Entity type:Individual
Prefix:MR
First Name:HUAN
Middle Name:PHU
Last Name:PHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:HUAN
Other - Middle Name:PHU
Other - Last Name:PHAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FRESCO
Mailing Address - Street 1:5252 EL CAJON BLVD APT 208
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-4762
Mailing Address - Country:US
Mailing Address - Phone:619-314-2728
Mailing Address - Fax:
Practice Address - Street 1:5252 EL CAJON BLVD APT 208
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-4762
Practice Address - Country:US
Practice Address - Phone:619-314-2728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-10
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744R1103XOther Service ProvidersSpecialistResearch Data Abstracter/Coder
No102X00000XBehavioral Health & Social Service ProvidersPoetry Therapist
No1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians
No171WH0202XOther Service ProvidersContractorHome Modifications
No174400000XOther Service ProvidersSpecialist
No177F00000XOther Service ProvidersLodging
No251X00000XAgenciesSupports Brokerage
No302F00000XManaged Care OrganizationsExclusive Provider Organization
No305S00000XManaged Care OrganizationsPoint of Service
No331L00000XSuppliersBlood Bank
No342000000XTransportation ServicesTransportation Network Company
No344800000XTransportation ServicesAir Carrier
No347C00000XTransportation ServicesPrivate Vehicle
No347D00000XTransportation ServicesTrain
No347E00000XTransportation ServicesTransportation Broker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA93638370A18274Medicaid