Healthcare Provider Details

I. General information

NPI: 1619079241
Provider Name (Legal Business Name): STEPHEN PHAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2006
Last Update Date: 07/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 S ORANGE AVE
ORLANDO FL
32806-2134
US

IV. Provider business mailing address

PO BOX 628296
ORLANDO FL
32862-8296
US

V. Phone/Fax

Practice location:
  • Phone: 407-841-5111
  • Fax: 904-346-0113
Mailing address:
  • Phone: 407-741-9418
  • Fax: 904-596-2761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberME0075785
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: