Provider Demographics
NPI:1336406859
Name:PHAM, BRYAN VAN (M D)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:VAN
Last Name:PHAM
Suffix:
Gender:M
Credentials:M D
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 17528
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-0528
Mailing Address - Country:US
Mailing Address - Phone:888-987-7975
Mailing Address - Fax:405-792-8910
Practice Address - Street 1:4500 E 9TH AVE STE 740
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80220-3926
Practice Address - Country:US
Practice Address - Phone:303-781-4485
Practice Address - Fax:720-274-0064
Is Sole Proprietor?:No
Enumeration Date:2012-04-20
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0058739207W00000X, 2084N0400X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO028468OtherKAISER COMMERCIAL NUMBER