MEDICARE: VANNA PHAM O.D.

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	9674T	TX

General Provider Information

NPI Number	:	1568022267
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VANNA PHAM O.D.

Provider Business Mailing Address
First Line	:	2808 PICKETT DR
Second Line	:
City	:	LEAGUE CITY
State	:	TX
Zip	:	77573-4857
Country	:	US
Telephone Number	:	832-508-4964
Fax Number	:

Provider Business Practice Location Address
First Line	:	1616 CLEAR LAKE CITY BLVD STE 103
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77062-8069
Country	:	US
Telephone Number	:	281-286-4343
Fax Number	:

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

Provider Enumeration Date	:	06/16/2019
Last Update Date	:	02/19/2020

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