Basic Information
| Provider Information | |||||||||
| NPI: | 1437319993 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHAM | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | MINH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 SUMMIT BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | BROOKHAVEN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303196410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709891634 | ||||||||
| FaxNumber: | 6783581759 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 PHILIP BLVD STE A | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708225560 | ||||||||
| FaxNumber: | 7708224989 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2008 | ||||||||
| LastUpdateDate: | 10/03/2018 | ||||||||
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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 | 207RG0100X | 071551 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 003146015 | 05 | GA | MEDICAID |