Provider Demographics
NPI:1306879283
Name:PHAN, MAI TUYET (MD)
Entity type:Individual
Prefix:DR
First Name:MAI
Middle Name:TUYET
Last Name:PHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CHRISTINE
Other - Middle Name:PHAN
Other - Last Name:HUYNH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:18625 SHERMAN WAY
Mailing Address - Street 2:SUITE #104
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-4148
Mailing Address - Country:US
Mailing Address - Phone:818-342-8171
Mailing Address - Fax:818-342-8173
Practice Address - Street 1:18625 SHERMAN WAY
Practice Address - Street 2:SUITE #104
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-4148
Practice Address - Country:US
Practice Address - Phone:818-342-8171
Practice Address - Fax:818-342-8173
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA051466207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A514660Medicaid
CA00A514660Medicaid
CAA51466Medicare ID - Type Unspecified