Healthcare Provider Details

I. General information

NPI: 1336601574
Provider Name (Legal Business Name): TIFFANY THIENTHAO PHAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2019
Last Update Date: 11/18/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11199 SORRENTO VALLEY RD STE 202
SAN DIEGO CA
92121-1334
US

IV. Provider business mailing address

11199 SORRENTO VALLEY RD STE 202
SAN DIEGO CA
92121-1334
US

V. Phone/Fax

Practice location:
  • Phone: 858-282-0212
  • Fax:
Mailing address:
  • Phone: 868-282-0212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberA202627
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: