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General NPI Number Information
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NPI Number | 1174879563
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Entity Type | Organization
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Legal Business Name | OPTOMETRICA O D P A
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Dates
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Enumeration Date | 08/03/2012
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Last Update Date | 10/01/2012
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Provider Practice Location Address
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Address Line | 1571 PERIWINKLE WAY
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City | SANIBEL
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State | FL
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Zip | 33957-4513
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Country | US
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Telephone | 239-560-6917
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Fax | 239-415-7341
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Provider Business Mailing Address
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Address Line | 6747 WILLOW LAKE CIR
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City | FORT MYERS
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State | FL
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Zip | 33966-1253
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Country | US
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Telephone | 239-560-6917
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Fax | 239-415-7341
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Authorized Official
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Title or Position | PRESIDENT / OWNER
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Name | DR. PHONG MICHAEL PHAM
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Credential | OD
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Telephone | 239-560-6917
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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 | OPC3502
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License Number State | FL
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