Healthcare Provider Details

I. General information

NPI: 1366939795
Provider Name (Legal Business Name): TOM PHAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2018
Last Update Date: 12/19/2022
Certification Date: 12/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4855 S MOORLAND RD FL 3
NEW BERLIN WI
53151-7494
US

IV. Provider business mailing address

PO BOX 845347
DALLAS TX
75284-5347
US

V. Phone/Fax

Practice location:
  • Phone: 262-432-7599
  • Fax: 262-432-7694
Mailing address:
  • Phone: 214-476-8559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number75525
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberT7331
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: