MEDICARE: DR. TAN-LONG PHAM MS, 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	OPC4085	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	U7179W	OTHER	FL	MEDICARE

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
3	OPC 4085	OTHER	FL	FL LICENSE
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1699766949
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TAN-LONG PHAM MS, OD

Provider Business Mailing Address
First Line	:	PO BOX 919771
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32891-9771
Country	:	US
Telephone Number	:	239-278-3600
Fax Number	:	239-226-4650

Provider Business Practice Location Address
First Line	:	316 DEL PRADO BLVD S
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33990-1710
Country	:	US
Telephone Number	:	239-226-2640
Fax Number	:	239-458-0178

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

Provider Enumeration Date	:	11/03/2005
Last Update Date	:	09/30/2020

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