Healthcare Provider Details

I. General information

NPI: 1306954037
Provider Name (Legal Business Name): HAN CAM PHAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 05/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 JOHNSON FERRY RD
ATLANTA GA
30342
US

IV. Provider business mailing address

2076 ASGARD CT
ATLANTA GA
30345
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-2490
  • Fax: 404-785-5837
Mailing address:
  • Phone: 404-325-7955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number25990
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: