Healthcare Provider Details

I. General information

NPI: 1457647869
Provider Name (Legal Business Name): PHAN HUNG Q DAO PHARM. D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2011
Last Update Date: 06/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2295 N IMPERIAL AVE
EL CENTRO CA
92243-1335
US

IV. Provider business mailing address

2295 N IMPERIAL AVE
EL CENTRO CA
92243
US

V. Phone/Fax

Practice location:
  • Phone: 760-482-5407
  • Fax:
Mailing address:
  • Phone: 858-689-2719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number57408
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: