Healthcare Provider Details

I. General information

NPI: 1609490861
Provider Name (Legal Business Name): VICTORIA CATHERINE PHOUMTHIPPHAVONG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2020
Last Update Date: 09/02/2025
Certification Date: 09/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2330 POST ST FL 6
SAN FRANCISCO CA
94115-3465
US

IV. Provider business mailing address

6201 GREENLEIGH AVE
MIDDLE RIVER MD
21220-2004
US

V. Phone/Fax

Practice location:
  • Phone: 415-353-8393
  • Fax: 415-353-9539
Mailing address:
  • Phone: 410-933-6423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberA203494
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberD0100801
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: