Provider Demographics
NPI:1598040495
Name:PHAN, KATHY (OD)
Entity Type:Individual
Prefix:DR
First Name:KATHY
Middle Name:
Last Name:PHAN
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 1:239 S LA CIENEGA BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-3328
Mailing Address - Country:US
Mailing Address - Phone:888-563-9888
Mailing Address - Fax:424-288-4893
Practice Address - Street 1:239 S LA CIENEGA BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-3328
Practice Address - Country:US
Practice Address - Phone:888-563-9888
Practice Address - Fax:424-288-4893
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-12
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14191TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist