Healthcare Provider Details

I. General information

NPI: 1174107551
Provider Name (Legal Business Name): ANDREW PHAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2021
Last Update Date: 08/08/2024
Certification Date: 08/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39400 PASEO PADRE PKWY
FREMONT CA
94538-2310
US

IV. Provider business mailing address

4439 MARGERY DR
FREMONT CA
94538-2609
US

V. Phone/Fax

Practice location:
  • Phone: 510-248-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A21461
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: