Provider Demographics
NPI:1194884387
Name:PHAM, BENJAMIN VAN (MD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:VAN
Last Name:PHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1378
Mailing Address - Street 2:
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94026-1378
Mailing Address - Country:US
Mailing Address - Phone:916-408-5580
Mailing Address - Fax:916-408-7297
Practice Address - Street 1:685 TWELVE BRIDGES DR STE F
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:CA
Practice Address - Zip Code:95648-8689
Practice Address - Country:US
Practice Address - Phone:916-408-5580
Practice Address - Fax:916-408-7297
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4060213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA480035043OtherRAILROAD
CA4724140001Medicare NSC
CA4724140003Medicare NSC
CA480035043OtherRAILROAD
CA4724140002Medicare NSC