1033119540 NPI number — DR. KHUONG DINH PHAN D.O.

Table of content: DR. KHUONG DINH PHAN D.O. (NPI 1033119540)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033119540 NPI number — DR. KHUONG DINH PHAN D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PHAN
Provider First Name:
KHUONG
Provider Middle Name:
DINH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1033119540
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/01/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8553 N BEACH ST
Provider Second Line Business Mailing Address:
PMB 296
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76244-4919
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-473-7197
Provider Business Mailing Address Fax Number:
817-473-7198

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
920 HIGHWAY 287 N
Provider Second Line Business Practice Location Address:
SUITE 308
Provider Business Practice Location Address City Name:
MANSFIELD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76063-2627
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-473-7197
Provider Business Practice Location Address Fax Number:
817-473-7198
Provider Enumeration Date:
07/26/2005

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: 207R00000X , with the licence number:  7520 , 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: P00434893 . This is a "MEDICARE RAILROAD PTAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8X9320 . This is a "BCBS PIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: DG4235 . This is a "MEDICARE RAILROAD GROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 180563202 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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