Basic Information
| Provider Information | |||||||||
| NPI: | 1316280522 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHAM | ||||||||
| FirstName: | JAX | ||||||||
| MiddleName: | HAI | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PHAM | ||||||||
| OtherFirstName: | HAI | ||||||||
| OtherMiddleName: | LONG | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 301 UNIVERSITY BLVD | ||||||||
| Address2: | |||||||||
| City: | GALVESTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775550709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4097472849 | ||||||||
| FaxNumber: | 4097727120 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 UNIVERSITY BLVD | ||||||||
| Address2: | |||||||||
| City: | GALVESTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775550709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4097472849 | ||||||||
| FaxNumber: | 4097727120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2013 | ||||||||
| LastUpdateDate: | 09/08/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 40021183-1817P | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.