Provider Demographics
NPI:1154461754
Name:PAN, MICAH VIENHOC (OD)
Entity Type:Individual
Prefix:DR
First Name:MICAH
Middle Name:VIENHOC
Last Name:PAN
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 1:15942 LOS SERRANOS COUNTRY CLUB DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-4531
Mailing Address - Country:US
Mailing Address - Phone:909-606-9943
Mailing Address - Fax:909-606-9118
Practice Address - Street 1:15942 LOS SERRANOS COUNTRY CLUB DR
Practice Address - Street 2:SUITE A
Practice Address - City:CHINO HILLS
Practice Address - State:CA
Practice Address - Zip Code:91709-4531
Practice Address - Country:US
Practice Address - Phone:909-606-9943
Practice Address - Fax:909-606-9118
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11582TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0115820Medicaid
CAU89159Medicare UPIN
CASD0115820Medicaid