Healthcare Provider Details

I. General information

NPI: 1598187924
Provider Name (Legal Business Name): MIMI ANHTU PHAN O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2014
Last Update Date: 06/13/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7677 CENTER AVE STE 301
HUNTINGTON BEACH CA
92647-3049
US

IV. Provider business mailing address

14726 RAMONA AVE STE 203
CHINO CA
91710-5730
US

V. Phone/Fax

Practice location:
  • Phone: 714-901-2007
  • Fax:
Mailing address:
  • Phone: 626-305-9100
  • Fax: 626-305-0152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number14705
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number14705
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number14705
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: