Provider Demographics
NPI:1144265414
Name:SANTOSO PHAM, JULIA CECILIA (DO)
Entity type:Individual
Prefix:
First Name:JULIA
Middle Name:CECILIA
Last Name:SANTOSO PHAM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:515 FAIRMOUNT AVE STE 350
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286-5466
Mailing Address - Country:US
Mailing Address - Phone:410-494-1355
Mailing Address - Fax:410-494-1361
Practice Address - Street 1:515 FAIRMOUNT AVE
Practice Address - Street 2:SUITE 350
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21286-5466
Practice Address - Country:US
Practice Address - Phone:410-494-1340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH59469207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDF19219Medicare UPIN
MD157676Medicare PIN
158635ZR0ZMedicare PIN
MDE965Medicare PIN