Provider Demographics
NPI:1801082508
Name:PHAM, NICK M (MD)
Entity type:Individual
Prefix:
First Name:NICK
Middle Name:M
Last Name:PHAM
Suffix:
Gender:M
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:PO BOX 2782
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-0782
Mailing Address - Country:US
Mailing Address - Phone:703-533-7673
Mailing Address - Fax:
Practice Address - Street 1:6408 SEVEN CORNERS PL STE F
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22044-2011
Practice Address - Country:US
Practice Address - Phone:703-533-7673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101244284207R00000X
VA0202205955183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
157385ZCALMedicare PIN