Provider Demographics
NPI:1215985379
Name:PHAN, KHANH-KATHY H (MD)
Entity type:Individual
Prefix:
First Name:KHANH-KATHY
Middle Name:H
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:PO BOX 746550
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6550
Mailing Address - Country:US
Mailing Address - Phone:888-236-2263
Mailing Address - Fax:434-975-1384
Practice Address - Street 1:3263 PROFFIT RD STE 201
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-5639
Practice Address - Country:US
Practice Address - Phone:434-654-4600
Practice Address - Fax:434-975-1384
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101248799207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVV0676AMedicare PIN
I53311Medicare UPIN
VAP01107282Medicare PIN