1649775925 NPI number — HIEU MITCHELL DUC PHAM MD

Table of content: HIEU MITCHELL DUC PHAM MD (NPI 1649775925)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649775925 NPI number — HIEU MITCHELL DUC PHAM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PHAM
Provider First Name:
HIEU
Provider Middle Name:
MITCHELL DUC
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PHAM
Provider Other First Name:
HIEU
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MITCHELL PHAM
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1649775925
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/21/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 863898
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLANO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75086-3898
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-939-0372
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2000 W 15TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLANO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75075-7331
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-612-9000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/28/2018

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: 208100000X , with the licence number:  E-15236 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6M1196 . This is a "MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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