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General NPI Number Information
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NPI Number | 1144989385
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Entity Type | Organization
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Legal Business Name | DR. JIMMY PHAN MEDICAL CORPORATION
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Dates
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Enumeration Date | 12/15/2021
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Last Update Date | 01/27/2022
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Provider Practice Location Address
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Address Line | 425 DIAMOND DR STE 103
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City | LAKE ELSINORE
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State | CA
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Zip | 92530-4495
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Country | US
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Telephone | 951-981-3122
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Fax |
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Provider Business Mailing Address
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Address Line | 425 DIAMOND DR STE 103
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City | LAKE ELSINORE
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State | CA
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Zip | 92530-4495
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Country | US
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Telephone | 951-981-3122
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. JIMMY NINH HOANG PHAN
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Credential | M.D.
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Telephone | 714-232-9493
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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