Healthcare Provider Details

I. General information

NPI: 1629787700
Provider Name (Legal Business Name): NHI BAO TRAM OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2022
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 STADIUM ST
SMYRNA DE
19977-2899
US

IV. Provider business mailing address

8614 WESTWOOD CENTER DR FL 9
VIENNA VA
22182-2442
US

V. Phone/Fax

Practice location:
  • Phone: 302-653-3400
  • Fax:
Mailing address:
  • Phone: 703-847-8899
  • Fax: 571-477-9227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberI3-0011462
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: