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General NPI Number Information
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NPI Number | 1366739195
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Entity Type | Organization
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Legal Business Name | CREST OPTOMETRY, INC
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Dates
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Enumeration Date | 06/30/2011
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Last Update Date | 12/31/2018
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Provider Practice Location Address
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Address Line | 173 N MORRISON AVE STE. E
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City | SAN JOSE
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State | CA
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Zip | 95126-2712
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Country | US
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Telephone | 408-372-7647
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Fax | 408-598-3332
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Provider Business Mailing Address
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Address Line | 173 N MORRISON AVE STE B
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City | SAN JOSE
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State | CA
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Zip | 95126-2712
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Country | US
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Telephone | 408-372-7647
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Fax | 408-598-3332
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. PHUONG B PHAM
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Credential | O.D.
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Telephone | 408-807-4344
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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 | 13778
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License Number State | CA
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