MEDICARE: DR. JEREMY PHAN OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	10019T	TX

General Provider Information

NPI Number	:	1093318933
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEREMY PHAN OD

Provider Business Mailing Address
First Line	:	5714 SANTA FE SPRINGS DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77041-5755
Country	:	US
Telephone Number	:	832-202-5641
Fax Number	:

Provider Business Practice Location Address
First Line	:	16535 SOUTHWEST FWY STE 230
Second Line	:
City	:	SUGAR LAND
State	:	TX
Zip	:	77479-2323
Country	:	US
Telephone Number	:	832-202-5641
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/20/2020
Last Update Date	:	11/20/2020

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