=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306739701
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DYLAN PHU OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2025
-----------------------------------------------------
Last Update Date | 07/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7100 VAN NUYS BLVD STE 208
-----------------------------------------------------
City | VAN NUYS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91405-3063
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-786-0796
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9580 KENNERLY ST
-----------------------------------------------------
City | TEMPLE CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91780-3837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 35959
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------