=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356809248
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEGACY FOOT & ANKLE SPECIALISTS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2019
-----------------------------------------------------
Last Update Date | 03/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1485 FM 1960 BYPASS RD E STE 200
-----------------------------------------------------
City | HUMBLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77338-3965
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-324-0444
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3031 HUMMINGBIRD LN
-----------------------------------------------------
City | HUMBLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77396-1853
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-620-6882
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/DIRECTOR
-----------------------------------------------------
Name | THOMAS MINH-NGOC PHAM
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 832-602-6882
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------