Healthcare Provider Details

I. General information

NPI: 1861610339
Provider Name (Legal Business Name): GIAO QUYNHTHI PHAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVENUE
FARMINGTON CT
06030-8040
US

IV. Provider business mailing address

263 FARMINGTON AVENUE
FARMINGTON CT
06030-8040
US

V. Phone/Fax

Practice location:
  • Phone: 606-792-1008
  • Fax: 860-679-4815
Mailing address:
  • Phone: 606-792-1008
  • Fax: 860-679-4815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0101255590
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number074215
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: