Healthcare Provider Details

I. General information

NPI: 1922740356
Provider Name (Legal Business Name): AUDREY MARIETTA PHAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2022
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 E PRESIDENT GEORGE BUSH HWY STE 107
RICHARDSON TX
75082-3565
US

IV. Provider business mailing address

839 S GOOD LATIMER EXPY APT 2386
DALLAS TX
75226-1848
US

V. Phone/Fax

Practice location:
  • Phone: 972-276-9902
  • Fax:
Mailing address:
  • Phone: 847-840-8790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberW7753
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: