Provider Demographics
NPI:1770928962
Name:PHAN, JIMMY NINH HOANG (MD)
Entity type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:NINH HOANG
Last Name:PHAN
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 1:425 DIAMOND DR STE 103
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-4495
Mailing Address - Country:US
Mailing Address - Phone:951-981-3122
Mailing Address - Fax:951-981-3123
Practice Address - Street 1:425 DIAMOND DR STE 103
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-4495
Practice Address - Country:US
Practice Address - Phone:951-981-3122
Practice Address - Fax:951-981-3123
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-02
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA141765208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics