MEDICARE: PHANILY EYECARE, PA

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	6247TG	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194912782
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHANILY EYECARE, PA

Provider Business Mailing Address
First Line	:	5846 NEW TERRITORY BLVD
Second Line	:
City	:	SUGAR LAND
State	:	TX
Zip	:	77479-5948
Country	:	US
Telephone Number	:	284-242-2946
Fax Number	:	281-242-2947

Provider Business Practice Location Address
First Line	:	5846 NEW TERRITORY BLVD
Second Line	:
City	:	SUGAR LAND
State	:	TX
Zip	:	77479-5948
Country	:	US
Telephone Number	:	281-242-2946
Fax Number	:	281-242-2947

Authorized Official
Title or Position	:	THERAPEUTIC OPTOMETRIST
Name	:	DR. HAOTAM THUY PHAN
Credential	:	OD
Telephone Number	:	281-242-2946

Provider Enumeration Date	:	09/27/2007
Last Update Date	:	07/08/2009

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