Provider Demographics
NPI:1467800664
Name:PHAM-VANG OPTOMETRY LLC
Entity Type:Organization
Organization Name:PHAM-VANG OPTOMETRY LLC
Other - Org Name:EYE DOC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAM-VANG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:763-316-4193
Mailing Address - Street 1:7074 BROOKLYN BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55429-1370
Mailing Address - Country:US
Mailing Address - Phone:763-639-0103
Mailing Address - Fax:
Practice Address - Street 1:7074 BROOKLYN BLVD
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55429-1370
Practice Address - Country:US
Practice Address - Phone:763-639-0103
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-27
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3056302R00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN635140001Medicaid
MNV09544Medicare PIN