Provider Demographics
NPI:1609521251
Name:PHAN, VI
Entity Type:Individual
Prefix:
First Name:VI
Middle Name:
Last Name:PHAN
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 1:25450 THE OLD RD
Mailing Address - Street 2:
Mailing Address - City:STEVENSON RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:91381-1704
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25450 THE OLD RD
Practice Address - Street 2:
Practice Address - City:STEVENSON RANCH
Practice Address - State:CA
Practice Address - Zip Code:91381-1704
Practice Address - Country:US
Practice Address - Phone:661-253-3662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-12
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35078152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist