Provider Demographics
NPI:1194715185
Name:PHAM, TAN DIEM (MD)
Entity type:Individual
Prefix:
First Name:TAN
Middle Name:DIEM
Last Name:PHAM
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:P.O. BOX 760
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01890
Mailing Address - Country:US
Mailing Address - Phone:781-756-7273
Mailing Address - Fax:781-721-0725
Practice Address - Street 1:88 MONTVALE AVENUE
Practice Address - Street 2:SUITE #3
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180
Practice Address - Country:US
Practice Address - Phone:781-481-9255
Practice Address - Fax:781-481-9257
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA206658207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAA32817Medicare ID - Type Unspecified
H45042Medicare UPIN