Provider Demographics
NPI:1538139381
Name:SOUTHAPHANH, PINHKEO (OD)
Entity Type:Individual
Prefix:
First Name:PINHKEO
Middle Name:
Last Name:SOUTHAPHANH
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 1:415 EAST OCEAN AVE
Mailing Address - Street 2:STE B
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436
Mailing Address - Country:US
Mailing Address - Phone:805-819-0742
Mailing Address - Fax:805-741-7367
Practice Address - Street 1:415 E OCEAN AVE
Practice Address - Street 2:STE B
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-6839
Practice Address - Country:US
Practice Address - Phone:805-682-9417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-24
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12359T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95600Medicare UPIN