Provider Demographics
NPI:1538472683
Name:LA, TUANH PHAN (OD)
Entity Type:Individual
Prefix:
First Name:TUANH
Middle Name:PHAN
Last Name:LA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:TUANN
Other - Middle Name:PHAN
Other - Last Name:LA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:423 ORCHARD HILL DR
Mailing Address - Street 2:
Mailing Address - City:CEDAR HILL
Mailing Address - State:TX
Mailing Address - Zip Code:75104-5418
Mailing Address - Country:US
Mailing Address - Phone:214-727-6542
Mailing Address - Fax:
Practice Address - Street 1:9500 CLIFFORD ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76108-4403
Practice Address - Country:US
Practice Address - Phone:817-367-7100
Practice Address - Fax:817-367-7102
Is Sole Proprietor?:No
Enumeration Date:2010-07-19
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7565T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB148627OtherMEDICARE INDIVIDUAL PTAN
TX219435902Medicaid