MEDICARE: PAULINA PHAN OD PA

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	5445TG	TX

General Provider Information

NPI Number	:	1902083173
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAULINA PHAN OD PA

Provider Business Mailing Address
First Line	:	3837 IRVING MALL
Second Line	:
City	:	IRVING
State	:	TX
Zip	:	75062-5159
Country	:	US
Telephone Number	:	972-255-6123
Fax Number	:	972-255-6174

Provider Business Practice Location Address
First Line	:	3837 IRVING MALL
Second Line	:
City	:	IRVING
State	:	TX
Zip	:	75062-5159
Country	:	US
Telephone Number	:	972-255-6123
Fax Number	:	972-255-6174

Authorized Official
Title or Position	:	OWNER
Name	:	DR. PAULINA PHAN
Credential	:	O.D.
Telephone Number	:	972-255-6123

Provider Enumeration Date	:	01/29/2008
Last Update Date	:	01/29/2008

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