Healthcare Provider Details

I. General information

NPI: 1447293048
Provider Name (Legal Business Name): LIEN TRAN PHAM M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 07/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 E DATE PL
SAN BERNARDINO CA
92404-4428
US

IV. Provider business mailing address

1717 E DATE PL
SAN BERNARDINO CA
92404-4428
US

V. Phone/Fax

Practice location:
  • Phone: 888-750-0036
  • Fax:
Mailing address:
  • Phone: 888-750-0036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA53375
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: