Provider Demographics
NPI:1376675702
Name:PHAN, VAN VIET (OD)
Entity Type:Individual
Prefix:DR
First Name:VAN
Middle Name:VIET
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 1:949 W MERCED TRAIL RD
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92865-2016
Mailing Address - Country:US
Mailing Address - Phone:714-998-3287
Mailing Address - Fax:
Practice Address - Street 1:1275 N AZUSA AVE
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91722-1246
Practice Address - Country:US
Practice Address - Phone:626-331-4491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13193152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist