Provider Demographics
NPI:1285165407
Name:PHAM, THEODORE (DO)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:
Last Name:PHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3262 SALT CREEK CIR
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68504-4761
Mailing Address - Country:US
Mailing Address - Phone:402-465-5600
Mailing Address - Fax:402-327-6074
Practice Address - Street 1:3262 SALT CREEK CIR
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68504-4761
Practice Address - Country:US
Practice Address - Phone:402-465-5600
Practice Address - Fax:402-327-6074
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-21
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102205715208000000X
390200000X
NE2271208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty