Provider Demographics
NPI:1912061623
Name:PHAM, JOHN TUAN (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:TUAN
Last Name:PHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5909 SE 92ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-4642
Mailing Address - Country:US
Mailing Address - Phone:503-771-0055
Mailing Address - Fax:503-771-1908
Practice Address - Street 1:5909 SE 92ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-4642
Practice Address - Country:US
Practice Address - Phone:503-771-0055
Practice Address - Fax:503-771-1908
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD023388207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR226856Medicaid
OR226856Medicaid
H92523Medicare UPIN
OR226856Medicaid