MEDICARE: MR. KIEM DUC 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	A40604	CA

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	:	1073535621
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KIEM DUC PHAM M.D.

Provider Business Mailing Address
First Line	:	4240 EL CAJON BLVD
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92105-1230
Country	:	US
Telephone Number	:	619-563-6142
Fax Number	:	619-563-0183

Provider Business Practice Location Address
First Line	:	4240 EL CAJON BLVD
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92105-1230
Country	:	US
Telephone Number	:	619-563-6142
Fax Number	:	619-563-0183

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

Provider Enumeration Date	:	07/24/2006
Last Update Date	:	07/08/2007

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