Healthcare Provider Details

I. General information

NPI: 1477623635
Provider Name (Legal Business Name): KEVIN PHAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 08/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S MAIN ST SUITE 101
ORANGE CA
92868-4507
US

IV. Provider business mailing address

500 S MAIN ST SUITE 101
ORANGE CA
92868-4507
US

V. Phone/Fax

Practice location:
  • Phone: 714-836-4204
  • Fax: 714-836-1809
Mailing address:
  • Phone: 714-836-4204
  • Fax: 714-836-1809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberA67209
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: