Provider Demographics
NPI:1760482996
Name:PHAM, MINO THU (MD)
Entity type:Individual
Prefix:
First Name:MINO
Middle Name:THU
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 1:17095 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-6004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17095 MAIN ST
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-6004
Practice Address - Country:US
Practice Address - Phone:760-948-6606
Practice Address - Fax:760-951-1609
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA82929207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACE7126Medicare PIN
CA00A829290Medicare PIN
CABA057XMedicare PIN
CAI17039Medicare UPIN