Basic Information
| Provider Information | |||||||||
| NPI: | 1538137369 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHAM | ||||||||
| FirstName: | QUEHUONG | ||||||||
| MiddleName: | H.T. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PHAM-MAST | ||||||||
| OtherFirstName: | QUEHUONG | ||||||||
| OtherMiddleName: | H.T. | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1406 W 5TH ST STE 301 | ||||||||
| Address2: | |||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407411688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063302370 | ||||||||
| FaxNumber: | 3527260079 | ||||||||
| Practice Location | |||||||||
| Address1: | 1406 W 5TH ST STE 301 | ||||||||
| Address2: | |||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407411688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063302370 | ||||||||
| FaxNumber: | 3527260079 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 08/27/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | ME80843 | FL | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1538137369 | 01 | FL | NPI | OTHER | 259385800 | 05 | FL | MEDICAID | 35762 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER |