Provider Demographics
NPI:1225790322
Name:PHAM, TIFFANY (OD)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:PHAM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2879 N WESTON ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92867-2286
Mailing Address - Country:US
Mailing Address - Phone:714-595-4623
Mailing Address - Fax:
Practice Address - Street 1:4200 CHINO HILLS PKWY STE 390
Practice Address - Street 2:
Practice Address - City:CHINO HILLS
Practice Address - State:CA
Practice Address - Zip Code:91709-5825
Practice Address - Country:US
Practice Address - Phone:909-393-9058
Practice Address - Fax:909-393-7298
Is Sole Proprietor?:No
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35028152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist