Healthcare Provider Details

I. General information

NPI: 1922462845
Provider Name (Legal Business Name): MICHAEL DANG PHAM DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2016
Last Update Date: 06/13/2022
Certification Date: 06/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9616 ARCHIBALD AVE STE 140
RANCHO CUCAMONGA CA
91730-7939
US

IV. Provider business mailing address

840 TOWNE CENTER DR
POMONA CA
91767-5900
US

V. Phone/Fax

Practice location:
  • Phone: 909-481-0436
  • Fax: 909-481-0457
Mailing address:
  • Phone: 909-505-1078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberDO034915
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code207WX0110X
TaxonomyPediatric Ophthalmology and Strabismus Specialist Physician Physician
License Number20A19100
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number20A19100
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: