Provider Demographics
NPI:1629450622
Name:TRAM PHAM OD, INC.
Entity Type:Organization
Organization Name:TRAM PHAM OD, INC.
Other - Org Name:STORY OPTOMETRY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TRAM
Authorized Official - Middle Name:L
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:408-920-7091
Mailing Address - Street 1:992 STORY RD
Mailing Address - Street 2:STE 40
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95122-2674
Mailing Address - Country:US
Mailing Address - Phone:408-920-7091
Mailing Address - Fax:408-920-7093
Practice Address - Street 1:992 STORY RD
Practice Address - Street 2:STE 40
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95122-2674
Practice Address - Country:US
Practice Address - Phone:408-920-7091
Practice Address - Fax:408-920-7093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-25
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11732T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0117321Medicaid
CASD0117320OtherPTAN
CASD0117321Medicaid