Healthcare Provider Details

I. General information

NPI: 1528045077
Provider Name (Legal Business Name): ANH-THU N. PHAN, OD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2005
Last Update Date: 02/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9665A MAIN ST
FAIRFAX VA
22031-3739
US

IV. Provider business mailing address

9665A MAIN ST
FAIRFAX VA
22031-3739
US

V. Phone/Fax

Practice location:
  • Phone: 703-978-2020
  • Fax: 703-978-6454
Mailing address:
  • Phone: 703-978-2020
  • Fax: 703-978-6454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. ANH-THU N. PHAN
Title or Position: PRESIDENT/DIRECTOR
Credential: O.D.
Phone: 571-236-6754