Provider Demographics
NPI:1750437497
Name:PHAM, MINH CONG (MD)
Entity type:Individual
Prefix:DR
First Name:MINH
Middle Name:CONG
Last Name:PHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2812 W CERVANTES ST
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32505-7159
Mailing Address - Country:US
Mailing Address - Phone:850-429-0474
Mailing Address - Fax:850-429-7275
Practice Address - Street 1:2812 W CERVANTES ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32505-7159
Practice Address - Country:US
Practice Address - Phone:850-429-0474
Practice Address - Fax:850-429-7275
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME76233208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL255860200Medicaid
FLG88319Medicare UPIN
FL255860200Medicaid
FL1750737497Medicare NSC