Healthcare Provider Details

I. General information

NPI: 1215509658
Provider Name (Legal Business Name): KIM PHAM OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2021
Last Update Date: 07/14/2021
Certification Date: 07/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

241 CORPORATE BLVD
NORFOLK VA
23502-4975
US

IV. Provider business mailing address

4505 MAIN ST STE 258
VIRGINIA BEACH VA
23462-3388
US

V. Phone/Fax

Practice location:
  • Phone: 757-622-2200
  • Fax:
Mailing address:
  • Phone: 832-863-8720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618003045
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: