Basic Information
Provider Information | |||||||||
NPI: | 1477940658 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PHAM | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | TRUNG | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10790 RANCHO BERNARDO RD | ||||||||
Address2: |   | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921275705 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7608277210 | ||||||||
FaxNumber: | 7608277225 | ||||||||
Practice Location | |||||||||
Address1: | 2176 SALK AVE | ||||||||
Address2: |   | ||||||||
City: | CARLSBAD | ||||||||
State: | CA | ||||||||
PostalCode: | 920087346 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7608277210 | ||||||||
FaxNumber: | 7608277225 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/24/2015 | ||||||||
LastUpdateDate: | 07/12/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/12/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 20A18260 | CA | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 390200000X | 286997 | NY | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207R00000X | 20A18260 | CA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.