Basic Information
| Provider Information | |||||||||
| NPI: | 1245282938 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHAM | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1276 S PEACHTREE ST | ||||||||
| Address2: | |||||||||
| City: | JASPER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759514916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4093845701 | ||||||||
| FaxNumber: | 4093844238 | ||||||||
| Practice Location | |||||||||
| Address1: | 1276 S PEACHTREE ST | ||||||||
| Address2: | |||||||||
| City: | JASPER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759514916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4093845701 | ||||||||
| FaxNumber: | 4093844238 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | K2098 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100627205 | 05 | TX | MEDICAID | 100627206 | 05 | TX | MEDICAID |