Healthcare Provider Details

I. General information

NPI: 1689607780
Provider Name (Legal Business Name): SANDY PHAM-VANG OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7074 BROOKLYN BLVD
BROOKLYN CENTER MN
55429-1370
US

IV. Provider business mailing address

7074 BROOKLYN BLVD
BROOKLYN CENTER MN
55429-1370
US

V. Phone/Fax

Practice location:
  • Phone: 763-316-4193
  • Fax: 763-363-0002
Mailing address:
  • Phone: 763-316-4193
  • Fax: 763-363-0002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number3056
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: