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General NPI Number Information
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NPI Number | 1013452234
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Entity Type | Organization
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Legal Business Name | DR JULIE PHAN OD INC
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Dates
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Enumeration Date | 12/23/2016
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Last Update Date | 12/23/2016
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Provider Practice Location Address
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Address Line | 1055 HARRIMAN PL
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City | SAN BERNARDINO
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State | CA
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Zip | 92408-4203
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Country | US
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Telephone | 909-799-3130
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Fax |
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Provider Business Mailing Address
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Address Line | 13250 DON JULIAN RD
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City | LA PUENTE
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State | CA
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Zip | 91746-2239
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Country | US
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Telephone | 626-382-9096
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Fax |
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. JULIE PHAN
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Credential | O.D.
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Telephone | 909-799-3130
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 14612TLG
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License Number State | CA
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