Provider Demographics
NPI:1609352798
Name:PHAN, RICHARD (OD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:PHAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 N HANOVER ST
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-5007
Mailing Address - Country:US
Mailing Address - Phone:714-515-9721
Mailing Address - Fax:
Practice Address - Street 1:200 MINOR LN
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94720
Practice Address - Country:US
Practice Address - Phone:510-642-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT33976-TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist