Healthcare Provider Details

I. General information

NPI: 1467445403
Provider Name (Legal Business Name): BAO TIEN PHAM D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 11/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6816 SOUTHPOINT PKWY SUITE 302
JACKSONVILLE FL
32216-1700
US

IV. Provider business mailing address

5377 COMMISSIONERS DR
JACKSONVILLE FL
32224-0830
US

V. Phone/Fax

Practice location:
  • Phone: 904-527-3135
  • Fax: 904-683-4293
Mailing address:
  • Phone: 904-527-3135
  • Fax: 904-683-4293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberOS7296
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: