Healthcare Provider Details

I. General information

NPI: 1144230897
Provider Name (Legal Business Name): MELANIE NGOCHAN PHAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 01/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7515 VAN NUYS BLVD
VAN NUYS CA
91405-1949
US

IV. Provider business mailing address

7515 VAN NUYS BLVD
VAN NUYS CA
91405-1949
US

V. Phone/Fax

Practice location:
  • Phone: 818-947-4079
  • Fax:
Mailing address:
  • Phone: 818-947-4079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License NumberA82302
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: