Provider Demographics
NPI:1073967584
Name:PHAM, CONNIE (DO)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:PHAM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 S CLARK ST STE 900
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60603-4043
Mailing Address - Country:US
Mailing Address - Phone:512-988-5355
Mailing Address - Fax:
Practice Address - Street 1:1320 WONDER WORLD DR STE 101
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-7558
Practice Address - Country:US
Practice Address - Phone:512-396-3911
Practice Address - Fax:512-353-0807
Is Sole Proprietor?:No
Enumeration Date:2016-04-20
Last Update Date:2025-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A23711207Q00000X
TXS1221207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
831947OtherMEDICARE
P02284117OtherRR MEDICARE
TX400345101Medicaid