Healthcare Provider Details

I. General information

NPI: 1225568645
Provider Name (Legal Business Name): TAI MINH PHAM MD/MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2017
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3925 OLD REDWOOD HWY
SANTA ROSA CA
95403-1719
US

IV. Provider business mailing address

5526 DUPONT DR
SANTA ROSA CA
95409-3847
US

V. Phone/Fax

Practice location:
  • Phone: 707-657-9260
  • Fax:
Mailing address:
  • Phone: 408-991-5658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA157565
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: