Healthcare Provider Details

I. General information

NPI: 1669456000
Provider Name (Legal Business Name): LAC HONG PHAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 N LAKEMONT AVE
WINTER PARK FL
32792-3214
US

IV. Provider business mailing address

157 N LAKEMONT AVE
WINTER PARK FL
32792-3214
US

V. Phone/Fax

Practice location:
  • Phone: 407-644-6618
  • Fax: 407-644-3755
Mailing address:
  • Phone: 407-644-6618
  • Fax: 407-644-3755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME 34155
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: