Healthcare Provider Details

I. General information

NPI: 1508427972
Provider Name (Legal Business Name): KTP FOOT AND ANKLE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2019
Last Update Date: 03/22/2020
Certification Date: 03/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1855 N FAIR OAKS AVE # 200
PASADENA CA
91103-1620
US

IV. Provider business mailing address

9392 RUSSELL AVE
GARDEN GROVE CA
92844-2354
US

V. Phone/Fax

Practice location:
  • Phone: 626-398-6300
  • Fax:
Mailing address:
  • Phone: 714-654-4607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: MR. KEVIN THANG DINH PHAM
Title or Position: PRESIDENT
Credential: DPM
Phone: 714-654-4607