Provider Demographics
NPI:1083429369
Name:MYDUNG PHAN
Entity type:Organization
Organization Name:MYDUNG PHAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED NUTRIONIST
Authorized Official - Prefix:
Authorized Official - First Name:MYDUNG
Authorized Official - Middle Name:THI
Authorized Official - Last Name:PHAN
Authorized Official - Suffix:
Authorized Official - Credentials:RDN
Authorized Official - Phone:480-918-4775
Mailing Address - Street 1:6637 N 58TH DR APT 3
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85301-3900
Mailing Address - Country:US
Mailing Address - Phone:480-918-4775
Mailing Address - Fax:
Practice Address - Street 1:6637 N 58TH DR APT 3
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-3900
Practice Address - Country:US
Practice Address - Phone:480-918-4775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RADADVANTAGE A PROFESSIONAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-02-12
Last Update Date:2025-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty
No136A00000XDietary & Nutritional Service ProvidersDietetic Technician, RegisteredGroup - Multi-Specialty
No171400000XOther Service ProvidersHealth & Wellness CoachGroup - Multi-Specialty
No172A00000XOther Service ProvidersDriverGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
No133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight ManagementGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ167030Medicaid