Basic Information
| Provider Information | |||||||||
| NPI: | 1043472640 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHAN | ||||||||
| FirstName: | PHILIP | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | PHAN | ||||||||
| OtherFirstName: | PHU | ||||||||
| OtherMiddleName: | GIA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 393 E WALNUT STREET | ||||||||
| Address2: | 3RD FLOOR - PHRS | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911880001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264057914 | ||||||||
| FaxNumber: | 8183754069 | ||||||||
| Practice Location | |||||||||
| Address1: | 8120 WOODMAN AVENUE | ||||||||
| Address2: | PANORAMA CITY MEDICAL CENTER | ||||||||
| City: | PANORAMA CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183752809 | ||||||||
| FaxNumber: | 8183754069 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2008 | ||||||||
| LastUpdateDate: | 10/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | MD439436 | PA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | MT192216 | PA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | A118484 | CA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.