=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912196676
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SCARSDALE VISION CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2007
-----------------------------------------------------
Last Update Date | 10/18/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10904 SCARSDALE BLVD STE 140
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77089-6034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-464-0885
-----------------------------------------------------
Fax | 281-464-0885
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10904 SCARSDALE BLVD STE 140
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77089-6034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-464-0885
-----------------------------------------------------
Fax | 281-464-0885
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MICHAEL TUAN PHAM
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 281-464-0885
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 5748TG
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------