Provider Demographics
NPI:1194721407
Name:PHAN, NGUYEN H (MD)
Entity type:Individual
Prefix:DR
First Name:NGUYEN
Middle Name:H
Last Name:PHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2350 N LAKE DR
Mailing Address - Street 2:STE 206
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53211-4528
Mailing Address - Country:US
Mailing Address - Phone:414-298-7280
Mailing Address - Fax:414-298-7281
Practice Address - Street 1:2350 N LAKE DR
Practice Address - Street 2:STE 206
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4528
Practice Address - Country:US
Practice Address - Phone:414-298-7280
Practice Address - Fax:414-298-7281
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI45546 020207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34379700Medicaid
WI01845Medicare ID - Type UnspecifiedMEDICARE NUMBER
WI1634-002Medicare PIN
WI34379700Medicaid
000002525-0361Medicare PIN
P00794206Medicare PIN
WIG87119Medicare UPIN