Provider Demographics
NPI:1730218678
Name:PHAM, SALLY THANH (DPM)
Entity type:Individual
Prefix:DR
First Name:SALLY
Middle Name:THANH
Last Name:PHAM
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 FENTON ST
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94550-4144
Mailing Address - Country:US
Mailing Address - Phone:925-455-1555
Mailing Address - Fax:925-292-7592
Practice Address - Street 1:48 FENTON ST
Practice Address - Street 2:
Practice Address - City:LIVERMORE
Practice Address - State:CA
Practice Address - Zip Code:94550-4144
Practice Address - Country:US
Practice Address - Phone:925-455-1555
Practice Address - Fax:925-292-7592
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4685213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6337710001OtherNSC PTAN
CA6337710001OtherNSC PTAN