Basic Information
| Provider Information | |||||||||
| NPI: | 1558516823 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHAM | ||||||||
| FirstName: | NGUYEN-PHUONG | ||||||||
| MiddleName: | DINH | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 160 N LINDEN AVE | ||||||||
| Address2: | #59 | ||||||||
| City: | RIALTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923765400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7143996219 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 16854 IVY AVE | ||||||||
| Address2: | |||||||||
| City: | FONTANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923351504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095801000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2008 | ||||||||
| LastUpdateDate: | 11/29/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A105426 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.