Provider Demographics
NPI:1497808794
Name:PHAM, MATT T (OD)
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:T
Last Name:PHAM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:HOAI
Other - Middle Name:T
Other - Last Name:PHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2218 RIVER RUN DR
Mailing Address - Street 2:#107
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-5877
Mailing Address - Country:US
Mailing Address - Phone:858-245-5147
Mailing Address - Fax:
Practice Address - Street 1:8080 PARKWAY DR
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-2104
Practice Address - Country:US
Practice Address - Phone:858-245-5147
Practice Address - Fax:619-589-3023
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11384T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU87540Medicare UPIN