Healthcare Provider Details

I. General information

NPI: 1194222422
Provider Name (Legal Business Name): TRUNG PHAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2018
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 N GOLDEN CIRCLE DR STE 109
SANTA ANA CA
92705-4022
US

IV. Provider business mailing address

250 N GOLDEN CIRCLE DR STE 109
SANTA ANA CA
92705-4022
US

V. Phone/Fax

Practice location:
  • Phone: 714-559-3846
  • Fax:
Mailing address:
  • Phone: 714-559-3846
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number193556
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2021025589
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number57.246123
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: