Healthcare Provider Details

I. General information

NPI: 1770928962
Provider Name (Legal Business Name): JIMMY NINH HOANG PHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2013
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: 951-981-3123
Mailing address:
  • Phone: 951-981-3122
  • Fax: 951-981-3123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number141765
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: