Provider Demographics
NPI:1497823306
Name:CHRISTYN MAI PHAN O D INC
Entity Type:Organization
Organization Name:CHRISTYN MAI PHAN O D INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTYN
Authorized Official - Middle Name:MAI
Authorized Official - Last Name:PHAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:714-636-9200
Mailing Address - Street 1:9862 CHAPMAN AVE STE A
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92841-2726
Mailing Address - Country:US
Mailing Address - Phone:714-636-9200
Mailing Address - Fax:714-636-9424
Practice Address - Street 1:9862 CHAPMAN AVE STE A
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92841-2726
Practice Address - Country:US
Practice Address - Phone:714-636-9200
Practice Address - Fax:714-636-9424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12640T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0126400Medicaid
CAW21176Medicare PIN