Healthcare Provider Details

I. General information

NPI: 1588790828
Provider Name (Legal Business Name): PHONG MICHAEL PHAM O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MICHAEL PHAM O.D.

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 06/08/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1571 PERIWINKLE WAY
SANIBEL FL
33957-4513
US

IV. Provider business mailing address

6747 WILLOW LAKE CIR
FORT MYERS FL
33966-1253
US

V. Phone/Fax

Practice location:
  • Phone: 239-472-4204
  • Fax: 239-415-7341
Mailing address:
  • Phone: 239-472-4204
  • Fax: 239-415-7341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC3502
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOPC3502
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: