Provider Demographics
NPI:1902918667
Name:PHAM, DIEN VAN (MD)
Entity Type:Individual
Prefix:
First Name:DIEN
Middle Name:VAN
Last Name:PHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 E ANAHEIM ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90813-3550
Mailing Address - Country:US
Mailing Address - Phone:562-591-0840
Mailing Address - Fax:562-591-4191
Practice Address - Street 1:855 E ANAHEIM ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813-3550
Practice Address - Country:US
Practice Address - Phone:562-591-0840
Practice Address - Fax:562-591-4191
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA39768207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A397680Medicaid
CAA39768Medicare ID - Type Unspecified
CA00A397680Medicaid