Provider Demographics
NPI:1629421995
Name:PHAM, MICHELLE (OD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
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 1:1360 EASTLAKE PKWY
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91915-4116
Mailing Address - Country:US
Mailing Address - Phone:619-482-1603
Mailing Address - Fax:480-893-8172
Practice Address - Street 1:1360 EASTLAKE PKWY
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91915-4116
Practice Address - Country:US
Practice Address - Phone:619-482-1603
Practice Address - Fax:619-482-4378
Is Sole Proprietor?:No
Enumeration Date:2016-07-21
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2146152W00000X
CA33503152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist