Healthcare Provider Details

I. General information

NPI: 1538161567
Provider Name (Legal Business Name): Y NGUYEN PHAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 06/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 S WASHINGTON AVE SUITE 100
MARSHALL TX
75670-5369
US

IV. Provider business mailing address

PO BOX 1325
MARSHALL TX
75671-1325
US

V. Phone/Fax

Practice location:
  • Phone: 903-927-6800
  • Fax: 903-935-0617
Mailing address:
  • Phone: 903-927-6800
  • Fax: 903-935-0617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberL5093
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: