MEDICARE: MONGNGHI THI PHAN O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	8229T	TX

General Provider Information

NPI Number	:	1801235387
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MONGNGHI THI PHAN O.D.

Provider Business Mailing Address
First Line	:	8024 SLIDE ROCK RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76137-5230
Country	:	US
Telephone Number	:	817-896-5028
Fax Number	:

Provider Business Practice Location Address
First Line	:	8024 SLIDE ROCK RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76137-5230
Country	:	US
Telephone Number	:	817-896-5028
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/18/2013
Last Update Date	:	06/18/2013

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