Provider Demographics
NPI:1669900676
Name:PHAM, MI (MD)
Entity type:Individual
Prefix:
First Name:MI
Middle Name:
Last Name:PHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 MUELLER BLVD STE 3S.066C
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-3079
Mailing Address - Country:US
Mailing Address - Phone:512-324-0165
Mailing Address - Fax:
Practice Address - Street 1:1001 LITTLE OAK WAY
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-5516
Practice Address - Country:US
Practice Address - Phone:122-558-8685
Practice Address - Fax:512-255-8869
Is Sole Proprietor?:No
Enumeration Date:2017-06-03
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10059353208000000X
TXS6710208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX413750701Medicaid