Provider Demographics
NPI:1740280189
Name:PHAM, THUY THANH (MD)
Entity type:Individual
Prefix:
First Name:THUY
Middle Name:THANH
Last Name:PHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2044 TRINITY OAKS BLVD
Mailing Address - Street 2:STE 235
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-3908
Mailing Address - Country:US
Mailing Address - Phone:727-375-5437
Mailing Address - Fax:727-375-0502
Practice Address - Street 1:2044 TRINITY OAKS BLVD
Practice Address - Street 2:STE 235
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34655-3908
Practice Address - Country:US
Practice Address - Phone:727-375-5437
Practice Address - Fax:727-375-0502
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME72415208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL251517200Medicaid
G44100Medicare UPIN