Provider Demographics
NPI:1316624133
Name:PHAM, MATTHEW
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:PHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12966 EUCLID ST STE 495
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-9209
Mailing Address - Country:US
Mailing Address - Phone:714-461-3687
Mailing Address - Fax:714-591-5015
Practice Address - Street 1:12966 EUCLID ST STE 495
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-9209
Practice Address - Country:US
Practice Address - Phone:714-461-3687
Practice Address - Fax:714-591-5015
Is Sole Proprietor?:No
Enumeration Date:2023-07-03
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X, 172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator