1215178736 NPI number — TUAN A. PHAM, MD, INC

Table of content: (NPI 1215178736)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215178736 NPI number — TUAN A. PHAM, MD, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TUAN A. PHAM, MD, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1215178736
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/18/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9333 BASELINE ROAD
Provider Second Line Business Mailing Address:
SUITE 160
Provider Business Mailing Address City Name:
RANCO CUCAMONGA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91730-1350
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-982-4116
Provider Business Mailing Address Fax Number:
909-941-4599

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9333 BASELINE RD
Provider Second Line Business Practice Location Address:
SUITE 160
Provider Business Practice Location Address City Name:
RANCHO CUCAMONGA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91730-1350
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-982-4116
Provider Business Practice Location Address Fax Number:
909-982-4599
Provider Enumeration Date:
03/12/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PHAM
Authorized Official First Name:
TUAN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
909-941-4777

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  A62514 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X , with the licence number: A62514 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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