Provider Demographics
NPI:1740259076
Name:PHAM, TAN NHAT (MD)
Entity type:Individual
Prefix:
First Name:TAN
Middle Name:NHAT
Last Name:PHAM
Suffix:
Gender:M
Credentials:MD
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 1330
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73070-1330
Mailing Address - Country:US
Mailing Address - Phone:405-307-5720
Mailing Address - Fax:405-307-5721
Practice Address - Street 1:3400 W TECUMSEH RD
Practice Address - Street 2:SUITE 203
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-1810
Practice Address - Country:US
Practice Address - Phone:405-307-5720
Practice Address - Fax:405-307-5721
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22538207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200063360BMedicaid
I45126Medicare UPIN
OK200063360BMedicaid