Healthcare Provider Details

I. General information

NPI: 1104386853
Provider Name (Legal Business Name): PETER PHAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 10/15/2026
Certification Date: 10/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

683 DOUGLAS AVE STE 101
ALTAMONTE SPRINGS FL
32714-2555
US

IV. Provider business mailing address

683 DOUGLAS AVE STE 101
ALTAMONTE SPRINGS FL
32714-2555
US

V. Phone/Fax

Practice location:
  • Phone: 407-478-1510
  • Fax: 407-478-1512
Mailing address:
  • Phone: 407-478-1510
  • Fax: 407-478-1512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberME166357
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: