Provider Demographics
NPI:1275570913
Name:PHAM, VAN D (OD)
Entity Type:Individual
Prefix:DR
First Name:VAN
Middle Name:D
Last Name:PHAM
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 1:525 HOWARD ST
Mailing Address - Street 2:FL 1
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-4005
Mailing Address - Country:US
Mailing Address - Phone:847-859-6365
Mailing Address - Fax:847-859-6385
Practice Address - Street 1:525 HOWARD ST
Practice Address - Street 2:FL 1
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-4005
Practice Address - Country:US
Practice Address - Phone:847-859-6365
Practice Address - Fax:847-859-6385
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008916152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046008916Medicaid
IL1626166OtherBCBSIL
ILU65632Medicare UPIN