Healthcare Provider Details

I. General information

NPI: 1679310114
Provider Name (Legal Business Name): THAO-NGUYEN PHAN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2024
Last Update Date: 03/20/2025
Certification Date: 03/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14634 MEMORIAL DR
HOUSTON TX
77079-7517
US

IV. Provider business mailing address

7205 CURPIN CV
AUSTIN TX
78754-5781
US

V. Phone/Fax

Practice location:
  • Phone: 281-741-7295
  • Fax:
Mailing address:
  • Phone: 512-501-9711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number11236T
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: