Healthcare Provider Details

I. General information

NPI: 1952791824
Provider Name (Legal Business Name): HAI PHAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2015
Last Update Date: 08/09/2021
Certification Date: 08/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5728 MAJOR BLVD SUITE 528
ORLANDO FL
32819-7962
US

IV. Provider business mailing address

5301 S CONGRESS AVE
ATLANTIS FL
33462-1149
US

V. Phone/Fax

Practice location:
  • Phone: 407-352-2542
  • Fax: 407-352-2547
Mailing address:
  • Phone: 877-832-2652
  • Fax: 800-792-9021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME 123287
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: