Provider Demographics
NPI:1427253012
Name:PHAM, VIVIEN DOAN (MD)
Entity type:Individual
Prefix:DR
First Name:VIVIEN
Middle Name:DOAN
Last Name:PHAM
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 1:1722 LOGANWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-9571
Mailing Address - Country:US
Mailing Address - Phone:325-651-5155
Mailing Address - Fax:
Practice Address - Street 1:157 N LAKEMONT AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-3214
Practice Address - Country:US
Practice Address - Phone:407-644-6618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 100800208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
3805159097OtherMYUTMB 3805159097-COMMERCIAL NUMBER