Healthcare Provider Details

I. General information

NPI: 1760482996
Provider Name (Legal Business Name): MINO THU PHAM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 11/09/2021
Certification Date: 11/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17095 MAIN ST
HESPERIA CA
92345-6004
US

IV. Provider business mailing address

17095 MAIN ST
HESPERIA CA
92345-6004
US

V. Phone/Fax

Practice location:
  • Phone: 760-948-6606
  • Fax: 760-951-1609
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA82929
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: