Healthcare Provider Details

I. General information

NPI: 1144989385
Provider Name (Legal Business Name): DR. JIMMY PHAN MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2021
Last Update Date: 01/27/2022
Certification Date: 01/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 DIAMOND DR STE 103
LAKE ELSINORE CA
92530-4495
US

IV. Provider business mailing address

425 DIAMOND DR STE 103
LAKE ELSINORE CA
92530-4495
US

V. Phone/Fax

Practice location:
  • Phone: 951-981-3122
  • Fax:
Mailing address:
  • Phone: 951-981-3122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JIMMY NINH HOANG PHAN
Title or Position: CEO
Credential: M.D.
Phone: 714-232-9493