Provider Demographics
NPI:1447262522
Name:BANG VU PHAM M D PROFESSIONAL
Entity type:Organization
Organization Name:BANG VU PHAM M D PROFESSIONAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT-COO
Authorized Official - Prefix:MRS
Authorized Official - First Name:DOLLY
Authorized Official - Middle Name:V
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:310-675-0395
Mailing Address - Street 1:12923 INGLEWOOD AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-5139
Mailing Address - Country:US
Mailing Address - Phone:310-675-0395
Mailing Address - Fax:310-675-0497
Practice Address - Street 1:12923 INGLEWOOD AVE STE 1
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250
Practice Address - Country:US
Practice Address - Phone:310-675-0395
Practice Address - Fax:310-675-0497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0044320Medicaid
CAW11047Medicare ID - Type Unspecified