Provider Demographics
NPI:1093318933
Name:PHAN, JEREMY (OD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:
Last Name:PHAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5714 SANTA FE SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77041-5755
Mailing Address - Country:US
Mailing Address - Phone:832-202-5641
Mailing Address - Fax:
Practice Address - Street 1:16535 SOUTHWEST FWY STE 230
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-2323
Practice Address - Country:US
Practice Address - Phone:832-202-5641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10019T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist