Provider Demographics
NPI:1578041547
Name:PHAM, TERESA (OD)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:PHAM
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 1:505 N JUDD PKWY NE
Mailing Address - Street 2:STE 109
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-2389
Mailing Address - Country:US
Mailing Address - Phone:919-557-0308
Mailing Address - Fax:
Practice Address - Street 1:2929 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2463
Practice Address - Country:US
Practice Address - Phone:513-559-3599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-01
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2558152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist