Healthcare Provider Details

I. General information

NPI: 1619166147
Provider Name (Legal Business Name): TRACY L. PHAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2007
Last Update Date: 05/03/2023
Certification Date: 05/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 W 39TH AVE
SAN MATEO CA
94403-4364
US

IV. Provider business mailing address

222 W 39TH AVE
SAN MATEO CA
94403-4364
US

V. Phone/Fax

Practice location:
  • Phone: 650-573-2222
  • Fax: 650-573-3772
Mailing address:
  • Phone: 650-573-2222
  • Fax: 650-573-3772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA99725
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: