Provider Demographics
NPI:1417485624
Name:PHAM, VY (OD)
Entity Type:Individual
Prefix:
First Name:VY
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 1:30040 AVENIDA CLASSICA
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-5415
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 ARTESIA BLVD
Practice Address - Street 2:STE 100
Practice Address - City:HERMOSA BEACH
Practice Address - State:CA
Practice Address - Zip Code:90254-2755
Practice Address - Country:US
Practice Address - Phone:310-372-0070
Practice Address - Fax:310-372-0073
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-01
Last Update Date:2021-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33671TLG152W00000X
CA33671152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty