=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770831976
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAI LAN PHAM O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2012
-----------------------------------------------------
Last Update Date | 07/08/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1375 N DAVIS RD
-----------------------------------------------------
City | SALINAS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93907-1991
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-751-9917
-----------------------------------------------------
Fax | 831-751-9842
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 375 OAK VIEW CT
-----------------------------------------------------
City | SAN JUAN BAUTISTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95045-9668
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-751-9917
-----------------------------------------------------
Fax | 831-751-9842
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 14484
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152WV0400X
-----------------------------------------------------
Taxonomy Name | Vision Therapy Optometrist
-----------------------------------------------------
License Number | 14484
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------