MEDICARE: DAC TAT PHAM M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	R3398	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063409761
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAC TAT PHAM M.D.

Provider Business Mailing Address
First Line	:	208 S MAIN AVE
Second Line	:
City	:	BRINKLEY
State	:	AR
Zip	:	72021-3210
Country	:	US
Telephone Number	:	870-734-3222
Fax Number	:	870-734-1341

Provider Business Practice Location Address
First Line	:	208 S MAIN AVE
Second Line	:
City	:	BRINKLEY
State	:	AR
Zip	:	72021-3210
Country	:	US
Telephone Number	:	870-734-3222
Fax Number	:	870-734-1341

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/29/2005
Last Update Date	:	04/04/2012

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