Provider Demographics
NPI:1164065959
Name:PHAN, KEVIN GIA-MINH (OD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:GIA-MINH
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 1:11084 SE 64TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97222-2319
Mailing Address - Country:US
Mailing Address - Phone:503-890-7209
Mailing Address - Fax:
Practice Address - Street 1:12000 SE 82ND AVE STE 2193
Practice Address - Street 2:
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97086-7746
Practice Address - Country:US
Practice Address - Phone:503-654-6217
Practice Address - Fax:503-654-9335
Is Sole Proprietor?:No
Enumeration Date:2019-10-24
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60964432152W00000X
OR4708152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist