Basic Information
| Provider Information | |||||||||
| NPI: | 1992008999 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHAN | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 31309 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900310309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234425100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1520 SAN PABLO ST | ||||||||
| Address2: | SUITE 1000 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900335310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234425100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2010 | ||||||||
| LastUpdateDate: | 08/12/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MED-PHYS-LIC-50617 | MT | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 10774A | WY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 16716 | NV | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MD-18837 | HI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MD60688829 | WA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MD179044 | OR | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MD2016-0833 | NM | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | DR.0057775 | CO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | M-13534 | ID | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 115268 | AK | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 53132 | AZ | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | A114260 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1902846306 | 01 | CA | GROUP NPI | OTHER | W18762 | 01 | CA | GROUP MEDICARE | OTHER | GR0100430 | 01 | CA | GROUP MEDICAL | OTHER |