Provider Demographics
NPI:1306954037
Name:PHAN, HAN CAM (MD)
Entity type:Individual
Prefix:
First Name:HAN
Middle Name:CAM
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 1:2076 ASGARD CT
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30345
Mailing Address - Country:US
Mailing Address - Phone:404-325-7955
Mailing Address - Fax:
Practice Address - Street 1:1001 JOHNSON FERRY RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342
Practice Address - Country:US
Practice Address - Phone:404-785-2490
Practice Address - Fax:404-785-5837
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL259902084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009992435Medicaid
AL009992445Medicaid
051555901Medicare ID - Type Unspecified
AL009992435Medicaid
051528109Medicare ID - Type Unspecified