Provider Demographics
NPI:1154570141
Name:DO, PHAN QUACH (DPH)
Entity type:Individual
Prefix:
First Name:PHAN
Middle Name:QUACH
Last Name:DO
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2908 TWIN LAKE DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73165-7351
Mailing Address - Country:US
Mailing Address - Phone:405-456-3705
Mailing Address - Fax:405-456-1716
Practice Address - Street 1:921 NE 13TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5007
Practice Address - Country:US
Practice Address - Phone:405-456-5473
Practice Address - Fax:405-456-1716
Is Sole Proprietor?:No
Enumeration Date:2008-09-15
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11868183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist