Provider Demographics
NPI:1982698767
Name:DUKE A PHAN MD NEUROLOGY INC
Entity Type:Organization
Organization Name:DUKE A PHAN MD NEUROLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:CORINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SEGOVIA DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-334-1215
Mailing Address - Street 1:17220 NEWHOPE ST
Mailing Address - Street 2:SUITE 217
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-4272
Mailing Address - Country:US
Mailing Address - Phone:714-546-4367
Mailing Address - Fax:714-546-4361
Practice Address - Street 1:17220 NEWHOPE ST
Practice Address - Street 2:SUITE 217
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-4272
Practice Address - Country:US
Practice Address - Phone:714-546-4367
Practice Address - Fax:714-546-4361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA511932084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A511930Medicaid
CA00A511930OtherBLUE SHIELD
CA00A511930OtherBLUE SHIELD
A51193Medicare ID - Type Unspecified
G31647Medicare UPIN