=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134010457
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TIFFANY H PHAN OD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2025
-----------------------------------------------------
Last Update Date | 07/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1214 N BEALE RD
-----------------------------------------------------
City | MARYSVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95901-6283
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-491-2732
-----------------------------------------------------
Fax | 530-491-2733
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9985 DONA NEELY WAY
-----------------------------------------------------
City | ELK GROVE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95757-6436
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-548-1575
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/OPTOMETRIST
-----------------------------------------------------
Name | DR. TIFFANY H PHAN
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 916-548-1575
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------