Provider Demographics
NPI:1831445113
Name:PHAM, MANH VAN (MD)
Entity type:Individual
Prefix:
First Name:MANH
Middle Name:VAN
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 1:1300 HOSPITAL LOOP
Mailing Address - Street 2:P.O.BOX 160
Mailing Address - City:BELCOURT
Mailing Address - State:ND
Mailing Address - Zip Code:58316
Mailing Address - Country:US
Mailing Address - Phone:701-477-6111
Mailing Address - Fax:701-477-2057
Practice Address - Street 1:1300 HOSPITAL LOOP
Practice Address - Street 2:
Practice Address - City:BELCOURT
Practice Address - State:ND
Practice Address - Zip Code:58316
Practice Address - Country:US
Practice Address - Phone:701-477-6111
Practice Address - Fax:701-477-2057
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-24
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY265088207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology