1467729194 NPI number — MONG-DIEP THI PHAM

Table of content: MONG-DIEP THI PHAM (NPI 1467729194)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467729194 NPI number — MONG-DIEP THI PHAM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PHAM
Provider First Name:
MONG-DIEP
Provider Middle Name:
THI
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1467729194
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/23/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12119 RANCHITO ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL MONTE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91732-3256
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2750 SAN GABRIEL BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSEMEAD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91770
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-288-2154
Provider Business Practice Location Address Fax Number:
626-288-2742
Provider Enumeration Date:
11/23/2011

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: 183500000X , with the licence number:  55568 , 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)