MEDICARE: ANTHONY THONG PHAN MD INC

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	207RG0300X	Geriatric Medicine (Internal Medicine) Physician	G83470	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00G834700	OTHER	CA	MEDICAL PROVIDER NUMBER
2	05D0989497	OTHER	CA	CLIA

General Provider Information

NPI Number	:	1730139353
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANTHONY THONG PHAN MD INC

Provider Business Mailing Address
First Line	:	1189 SWALLOW LN STE 110
Second Line	:
City	:	SIMI VALLEY
State	:	CA
Zip	:	93065-3157
Country	:	US
Telephone Number	:	805-526-3213
Fax Number	:	805-583-5929

Provider Business Practice Location Address
First Line	:	1189 SWALLOW LN STE 110
Second Line	:
City	:	SIMI VALLEY
State	:	CA
Zip	:	93065-3157
Country	:	US
Telephone Number	:	805-526-3213
Fax Number	:	805-583-5929

Authorized Official
Title or Position	:	PRESIDENT CEO
Name	:	DR. ANTHONY THONG PHAN
Credential	:	M.D.
Telephone Number	:	805-526-3213

Provider Enumeration Date	:	05/12/2006
Last Update Date	:	08/21/2019

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