Basic Information
Provider Information | |||||||||
NPI: | 1821040866 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PHAM | ||||||||
FirstName: | JUSTIN | ||||||||
MiddleName: | HUNG | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7026 OLD KATY RD STE 276 | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770242187 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7136217436 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 7026 OLD KATY RD STE 276 | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770242187 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7136217436 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/17/2006 | ||||||||
LastUpdateDate: | 10/13/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/13/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | A72116 | CA | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD16575 | RI | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | P3059 | TX | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 00A711260 | 01 |   | BLUE SHIELD | OTHER | 00A711260 | 05 | CA |   | MEDICAID | 7100056140 | 05 | KY |   | MEDICAID | 2927677 | 05 | OH |   | MEDICAID | 102062266 0001 | 05 | PA |   | MEDICAID | 102062266 0005 | 05 | PA |   | MEDICAID |