1205948296 NPI number — DR. VINCENT C PHAN

Table of content: DR. VINCENT C PHAN (NPI 1205948296)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205948296 NPI number — DR. VINCENT C PHAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PHAN
Provider First Name:
VINCENT
Provider Middle Name:
C
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205948296
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16811 SOUTHWEST FWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUGAR LAND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77479-4728
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-690-4678
Provider Business Mailing Address Fax Number:
281-565-8808

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16811 SOUTHWEST FWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUGAR LAND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77479
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-690-4678
Provider Business Practice Location Address Fax Number:
281-565-8808
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  K1278 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XS0106X , with the licence number: K1278 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 144768206 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2630736 . This is a "AETNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8BP174 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 144768202 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00732726 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 144768204 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 144768205 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 610119705 . This is a "US DEPT OF LABOR" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 144768201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01055722 . This is a "RR MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 144768203 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 144768207 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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