Basic Information
| Provider Information | |||||||||
| NPI: | 1295001592 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHAN | ||||||||
| FirstName: | KIM | ||||||||
| MiddleName: | MINH | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2466 | ||||||||
| Address2: | |||||||||
| City: | PALM SPRINGS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922632466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604164800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1180 N INDIAN CANYON DR STE E218 | ||||||||
| Address2: | |||||||||
| City: | PALM SPRINGS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922624885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604164800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2012 | ||||||||
| LastUpdateDate: | 09/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 012123 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 20A13018 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.