Provider Demographics
NPI:1124656004
Name:PHAN, THANH MINH (MD)
Entity type:Individual
Prefix:
First Name:THANH
Middle Name:MINH
Last Name:PHAN
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 1:9229 BLUEBONNET BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-2808
Mailing Address - Country:US
Mailing Address - Phone:225-215-7498
Mailing Address - Fax:225-922-3788
Practice Address - Street 1:9229 BLUEBONNET BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-2808
Practice Address - Country:US
Practice Address - Phone:225-215-7498
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-27
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3334292084P0800X
390200000X
LA3427402084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA322686OtherTRAINING LICENSE NUMBER
LA342740OtherLOUISIANA STATE MEDICAL LICENSE