Provider Demographics
NPI:1104261700
Name:DUNG MY PHAN MD INC
Entity type:Organization
Organization Name:DUNG MY PHAN MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DUNG
Authorized Official - Middle Name:MY
Authorized Official - Last Name:PHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:408-274-3881
Mailing Address - Street 1:1693 FLANIGAN DR
Mailing Address - Street 2:SUITE #100
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95121-1683
Mailing Address - Country:US
Mailing Address - Phone:408-274-3881
Mailing Address - Fax:408-274-9053
Practice Address - Street 1:1693 FLANIGAN DR
Practice Address - Street 2:SUITE #100
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95121-1683
Practice Address - Country:US
Practice Address - Phone:408-274-3881
Practice Address - Fax:408-274-9053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-08
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA42236207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A422360Medicare PIN