Provider Demographics
NPI:1376116558
Name:THAN, VICKY HONG PHUONG (OD)
Entity Type:Individual
Prefix:
First Name:VICKY
Middle Name:HONG PHUONG
Last Name:THAN
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 1:16230 STATE ROAD 54
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:FL
Mailing Address - Zip Code:33556-3729
Mailing Address - Country:US
Mailing Address - Phone:813-926-5993
Mailing Address - Fax:
Practice Address - Street 1:16230 STATE ROAD 54
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:FL
Practice Address - Zip Code:33556-3729
Practice Address - Country:US
Practice Address - Phone:813-926-5993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-23
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC5980152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist