Healthcare Provider Details

I. General information

NPI: 1700814944
Provider Name (Legal Business Name): TRINH CONG PHAM D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 FAIRMOUNT AVE SUITE 350
TOWSON MD
21286-5466
US

IV. Provider business mailing address

515 FAIRMOUNT AVE # 350
TOWSON MD
21286-5466
US

V. Phone/Fax

Practice location:
  • Phone: 410-494-1340
  • Fax: 410-494-1240
Mailing address:
  • Phone: 410-494-1355
  • Fax: 410-494-1361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberH59518
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: