Provider Demographics
NPI:1881357895
Name:MESOMSUB, PHANTHONG (DACM, LAC)
Entity type:Individual
Prefix:DR
First Name:PHANTHONG
Middle Name:
Last Name:MESOMSUB
Suffix:
Gender:M
Credentials:DACM, LAC
Other - Prefix:DR
Other - First Name:DREW
Other - Middle Name:
Other - Last Name:MESOMSUB
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:278 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94114-3023
Mailing Address - Country:US
Mailing Address - Phone:510-759-8349
Mailing Address - Fax:
Practice Address - Street 1:1021 SANCHEZ ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94114-3312
Practice Address - Country:US
Practice Address - Phone:510-759-8349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-17
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19031171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist