Basic Information
Provider Information | |||||||||
NPI: | 1982087391 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PHAM | ||||||||
FirstName: | JIMMY TAM HUY | ||||||||
MiddleName: | TAM HUY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 9602 | ||||||||
Address2: |   | ||||||||
City: | MISSION HILLS | ||||||||
State: | CA | ||||||||
PostalCode: | 913469602 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8188375559 | ||||||||
FaxNumber: | 8187924793 | ||||||||
Practice Location | |||||||||
Address1: | 15990 TUSCOLA RD | ||||||||
Address2: |   | ||||||||
City: | APPLE VALLEY | ||||||||
State: | CA | ||||||||
PostalCode: | 923072111 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4422840080 | ||||||||
FaxNumber: | 7609463095 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/02/2015 | ||||||||
LastUpdateDate: | 07/28/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/28/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 5315072508 | MI | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | 5101022112 | MI | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | 20A16546 | CA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RN0300X | 20A16546 | CA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
No ID Information.