Healthcare Provider Details

I. General information

NPI: 1750045720
Provider Name (Legal Business Name): JONATHAN NGUYEN-KHOI PHAM OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2021
Last Update Date: 10/26/2021
Certification Date: 09/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 CLEMENT STREET EYE CLINIC
SAN FRANCISCO CA
94121-1563
US

IV. Provider business mailing address

3333 CLEMENT ST APT 5
SAN FRANCISCO CA
94121-1640
US

V. Phone/Fax

Practice location:
  • Phone: 410-221-4810
  • Fax:
Mailing address:
  • Phone: 510-364-6529
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number39474
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: