Provider Demographics
NPI:1811273600
Name:PHAM, MAIKHOI T (DPM, MBA)
Entity type:Individual
Prefix:DR
First Name:MAIKHOI
Middle Name:T
Last Name:PHAM
Suffix:
Gender:F
Credentials:DPM, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:538 SE PORT ST LUCIE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34984-5108
Mailing Address - Country:US
Mailing Address - Phone:772-871-5900
Mailing Address - Fax:772-871-1197
Practice Address - Street 1:538 SE PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34984-5108
Practice Address - Country:US
Practice Address - Phone:772-871-5900
Practice Address - Fax:772-871-1197
Is Sole Proprietor?:No
Enumeration Date:2011-10-25
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2029213E00000X
FLPO3506213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX318118202Medicaid
TX318118201Medicaid
FL9426400Medicaid
TXP01144991OtherMEDICARE TRA
FLHN974ZMedicare PIN
TX278500YPREMedicare PIN
TX318118202Medicaid
TXP01144991Medicare PIN
TXTXB161596Medicare PIN
TX278500YPT7Medicare PIN