Provider Demographics
NPI:1548231038
Name:PHAM, THUY LE THU
Entity Type:Individual
Prefix:
First Name:THUY
Middle Name:LE THU
Last Name:PHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17617 PIONEER BLVD
Mailing Address - Street 2:
Mailing Address - City:ARTESIA
Mailing Address - State:CA
Mailing Address - Zip Code:90701-4008
Mailing Address - Country:US
Mailing Address - Phone:562-924-2020
Mailing Address - Fax:
Practice Address - Street 1:17617 PIONEER BLVD
Practice Address - Street 2:
Practice Address - City:ARTESIA
Practice Address - State:CA
Practice Address - Zip Code:90701-4008
Practice Address - Country:US
Practice Address - Phone:562-924-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10157T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD010157Medicaid
CACB218668Medicare PIN
CA6963970001Medicare NSC
CAOP10157Medicare PIN
CAU46822Medicare UPIN