Provider Demographics
NPI:1871804328
Name:PHAN, KHANH BAO (DO)
Entity type:Individual
Prefix:DR
First Name:KHANH
Middle Name:BAO
Last Name:PHAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1651 EARL ST
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083-5531
Mailing Address - Country:US
Mailing Address - Phone:908-591-9200
Mailing Address - Fax:
Practice Address - Street 1:1651 EARL ST
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-5531
Practice Address - Country:US
Practice Address - Phone:908-591-9200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-30
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB08718100208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics