Provider Demographics
NPI:1063409761
Name:PHAM, DAC TAT (MD)
Entity type:Individual
Prefix:
First Name:DAC
Middle Name:TAT
Last Name:PHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 S MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:BRINKLEY
Mailing Address - State:AR
Mailing Address - Zip Code:72021-3210
Mailing Address - Country:US
Mailing Address - Phone:870-734-3222
Mailing Address - Fax:870-734-1341
Practice Address - Street 1:208 S MAIN AVE
Practice Address - Street 2:
Practice Address - City:BRINKLEY
Practice Address - State:AR
Practice Address - Zip Code:72021-3210
Practice Address - Country:US
Practice Address - Phone:870-734-3222
Practice Address - Fax:870-734-1341
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-29
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR3398207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR103572001Medicaid
ARD17044Medicare UPIN