Healthcare Provider Details

I. General information

NPI: 1508152281
Provider Name (Legal Business Name): NIAM PHAN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2011
Last Update Date: 07/01/2024
Certification Date: 07/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 SERRAMONTE CTR
DALY CITY CA
94015-2345
US

IV. Provider business mailing address

1509 VIRGINIA AVE
WEST SACRAMENTO CA
95691-3901
US

V. Phone/Fax

Practice location:
  • Phone: 201-572-4039
  • Fax:
Mailing address:
  • Phone: 209-380-8145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number14181
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License Number14181
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: